Provider Demographics
NPI:1366047235
Name:MOUA, TONY KONG (PHD)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:KONG
Last Name:MOUA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 ENGLISH ST
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5204
Mailing Address - Country:US
Mailing Address - Phone:651-230-7857
Mailing Address - Fax:
Practice Address - Street 1:4800 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2844
Practice Address - Country:US
Practice Address - Phone:651-762-3864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist