Provider Demographics
NPI:1124658471
Name:QUACH-TRAN, TINA TUYET
Entity type:Individual
Prefix:
First Name:TINA TUYET
Middle Name:
Last Name:QUACH-TRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TUYET
Other - Middle Name:T
Other - Last Name:QUACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12666 BROOKHURST ST STE 110
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4866
Mailing Address - Country:US
Mailing Address - Phone:714-705-6992
Mailing Address - Fax:714-591-0591
Practice Address - Street 1:6552 BOLSA AVE STE A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2656
Practice Address - Country:US
Practice Address - Phone:714-916-5383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104601835P0018X
CA51045183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty