Provider Demographics
NPI:1538729223
Name:PHAN, LISA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 N CITRUS AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-3909
Mailing Address - Country:US
Mailing Address - Phone:626-334-7872
Mailing Address - Fax:
Practice Address - Street 1:367 N CITRUS AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-3909
Practice Address - Country:US
Practice Address - Phone:626-334-7872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist