Provider Demographics
NPI:1174781991
Name:NGUYEN, THAO PHUONG (PHARM D)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:PHUONG
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4544 MEREDITH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1537
Mailing Address - Country:US
Mailing Address - Phone:714-873-2438
Mailing Address - Fax:
Practice Address - Street 1:16491 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530
Practice Address - Country:US
Practice Address - Phone:951-674-0309
Practice Address - Fax:951-674-0419
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA183500000XOtherPHARMACIST