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General NPI Number Information
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NPI Number | 1407163967
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Entity Type | Organization
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Legal Business Name | MAILAN HERITAGE PHARMACY
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Dates
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Enumeration Date | 09/05/2010
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Last Update Date | 08/01/2019
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Provider Practice Location Address
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Address Line | 14441 BEACH BLVD STE 108
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City | WESTMINSTER
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State | CA
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Zip | 92683
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Country | US
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Telephone | 714-899-4960
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Fax | 714-876-6011
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Provider Business Mailing Address
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Address Line | 14441 BEACH BLVD STE 108
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City | WESTMINSTER
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State | CA
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Zip | 92683
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Country | US
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Telephone | 714-899-4960
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Fax | 714-876-6011
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Authorized Official
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Title or Position | PIC/CEO
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Name | PHUONG THI NGOC PHAM
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Credential | PHARM D.
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Telephone | 714-899-4960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY50316
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License Number State | CA
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