MEDICARE: SANDY DIEMLY PHAN PHARMACIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	49318	CA

General Provider Information

NPI Number	:	1235411687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDY DIEMLY PHAN PHARMACIST

Provider Business Mailing Address
First Line	:	12002 HARBOR BLVD
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-4002
Country	:	US
Telephone Number	:	714-663-2850
Fax Number	:	714-663-9319

Provider Business Practice Location Address
First Line	:	12002 HARBOR BLVD
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-4002
Country	:	US
Telephone Number	:	714-663-2850
Fax Number	:	714-663-9319

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2011
Last Update Date	:	09/12/2011

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