Provider Demographics
NPI:1992025514
Name:NGUYEN, PHUONG
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10561 KEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-5319
Mailing Address - Country:US
Mailing Address - Phone:714-531-9447
Mailing Address - Fax:
Practice Address - Street 1:17126 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-5905
Practice Address - Country:US
Practice Address - Phone:951-780-3343
Practice Address - Fax:951-780-6733
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-05
Last Update Date:2010-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist