Provider Demographics
NPI:1225464936
Name:PHAN, LAI PHUC (PHARMD)
Entity type:Individual
Prefix:
First Name:LAI
Middle Name:PHUC
Last Name:PHAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13804 29TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATAC
Mailing Address - State:WA
Mailing Address - Zip Code:98168-3852
Mailing Address - Country:US
Mailing Address - Phone:206-619-6848
Mailing Address - Fax:
Practice Address - Street 1:16251 SYLVESTER RD SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3017
Practice Address - Country:US
Practice Address - Phone:206-244-9970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60393203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist