Provider Demographics
NPI:1548801251
Name:NGUYEN, THEODORE PHAM (PHARMD, BCPS)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:PHAM
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S VERMONT AVE # 21-097
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1992
Mailing Address - Country:US
Mailing Address - Phone:714-767-1878
Mailing Address - Fax:
Practice Address - Street 1:529 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1511
Practice Address - Country:US
Practice Address - Phone:213-629-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23666183500000X
CA786789183500000X, 1835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy