Provider Demographics
NPI:1427865047
Name:NGUYEN, BAO
Entity type:Individual
Prefix:
First Name:BAO
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 TRAFTON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-2639
Mailing Address - Country:US
Mailing Address - Phone:413-209-6261
Mailing Address - Fax:
Practice Address - Street 1:111 ALBANY TPKE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019-2507
Practice Address - Country:US
Practice Address - Phone:860-693-8077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist