Provider Demographics
NPI:1174807630
Name:TRUONG, DALTON
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:TRUONG
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 1:7015 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711
Mailing Address - Country:US
Mailing Address - Phone:559-440-1404
Mailing Address - Fax:
Practice Address - Street 1:7015 N WEST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711
Practice Address - Country:US
Practice Address - Phone:559-440-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56796183500000X
TX41619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist