=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104314392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY PHAM RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2018
-----------------------------------------------------
Last Update Date | 04/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 MOUNT HERMON RD
-----------------------------------------------------
City | SCOTTS VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95066-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-420-9113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18710 NEWSOM AVE
-----------------------------------------------------
City | CUPERTINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95014-3855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 77084
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------