MEDICARE: DR. MARIE MAR PHAN PHARM. D.

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	47496	CA

General Provider Information

NPI Number	:	1386944379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIE MAR PHAN PHARM. D.

Provider Business Mailing Address
First Line	:	350 N LEMON AVE
Second Line	:
City	:	WALNUT
State	:	CA
Zip	:	91789-2345
Country	:	US
Telephone Number	:	909-595-7431
Fax Number	:	909-595-7925

Provider Business Practice Location Address
First Line	:	350 N LEMON AVE
Second Line	:
City	:	WALNUT
State	:	CA
Zip	:	91789-2345
Country	:	US
Telephone Number	:	909-595-7431
Fax Number	:	909-595-7925

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

Provider Enumeration Date	:	10/25/2010
Last Update Date	:	10/25/2010

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