MEDICARE: DR. SALLY NGOC 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	52582	CA

General Provider Information

NPI Number	:	1457690349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALLY NGOC PHAN PHARM-D

Provider Business Mailing Address
First Line	:	3045 CALLE DE LAS ESTRELLA
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95148-3400
Country	:	US
Telephone Number	:	916-798-6387
Fax Number	:

Provider Business Practice Location Address
First Line	:	3045 CALLE DE LAS ESTRELLA
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95148-3400
Country	:	US
Telephone Number	:	916-798-6387
Fax Number	:

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

Provider Enumeration Date	:	02/12/2013
Last Update Date	:	02/12/2013

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