Provider Demographics
NPI:1033723523
Name:TRUONG, LEON (PHARMD)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:TRUONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-5120
Mailing Address - Country:US
Mailing Address - Phone:409-381-8396
Mailing Address - Fax:
Practice Address - Street 1:1250 S WHEELER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5120
Practice Address - Country:US
Practice Address - Phone:409-381-8396
Practice Address - Fax:409-384-7480
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1134134042Medicaid