Provider Demographics
NPI:1023386497
Name:HUYNH, LUONG TRACH
Entity Type:Individual
Prefix:
First Name:LUONG
Middle Name:TRACH
Last Name:HUYNH
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 1:812 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5615
Mailing Address - Country:US
Mailing Address - Phone:530-743-4629
Mailing Address - Fax:530-743-8574
Practice Address - Street 1:812 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5615
Practice Address - Country:US
Practice Address - Phone:530-743-4629
Practice Address - Fax:530-743-8574
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA476020Medicaid
CA5761090001Medicare NSC