Provider Demographics
NPI:1437731767
Name:NGUYEN, HOA THAI
Entity type:Individual
Prefix:
First Name:HOA
Middle Name:THAI
Last Name:NGUYEN
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 1:12086 JEWEL FISH LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7141
Mailing Address - Country:US
Mailing Address - Phone:407-572-9853
Mailing Address - Fax:
Practice Address - Street 1:11930 NARCOOSSEE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-6900
Practice Address - Country:US
Practice Address - Phone:407-204-2026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019724300Medicaid