Provider Demographics
NPI:1932817327
Name:NGUYEN, JIMY
Entity type:Individual
Prefix:
First Name:JIMY
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 1:1929 BELOIT AVE APT 220
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12746 W JEFFERSON BLVD STE 3160
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2778
Practice Address - Country:US
Practice Address - Phone:310-862-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist