Provider Demographics
NPI:1043813934
Name:NGUYEN, TY
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 JACKDAW ALY
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3298 EDGMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-3105
Practice Address - Country:US
Practice Address - Phone:610-876-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP442372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist