Provider Demographics
NPI:1982980967
Name:NGUYEN, PHUONGTAM NGOC (PHARMD)
Entity type:Individual
Prefix:
First Name:PHUONGTAM
Middle Name:NGOC
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:TAM
Other - Middle Name:NGOC
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2609 AUGUSTA
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1201
Mailing Address - Country:US
Mailing Address - Phone:951-360-1911
Mailing Address - Fax:
Practice Address - Street 1:6170 HAMNER AVE
Practice Address - Street 2:
Practice Address - City:MIRA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91752-3121
Practice Address - Country:US
Practice Address - Phone:951-360-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH #60162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist