Provider Demographics
NPI:1154901643
Name:NGUYEN, JOHNNY (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:NGUYEN
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 1:3755 RIVER LOOP DR
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-8802
Mailing Address - Country:US
Mailing Address - Phone:228-326-4322
Mailing Address - Fax:
Practice Address - Street 1:10290 DIBERVILLE BLVD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2536
Practice Address - Country:US
Practice Address - Phone:228-271-6751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023750183500000X
MSE-100021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist