Provider Demographics
NPI:1154695419
Name:LAI, QUYEN MONG (PHARMACIST)
Entity type:Individual
Prefix:
First Name:QUYEN
Middle Name:MONG
Last Name:LAI
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 ALTA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92158-0001
Mailing Address - Country:US
Mailing Address - Phone:619-661-6500
Mailing Address - Fax:619-671-7588
Practice Address - Street 1:408 ALTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92158-0001
Practice Address - Country:US
Practice Address - Phone:619-661-6500
Practice Address - Fax:619-671-7588
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 45684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist