Provider Demographics
NPI:1073926879
Name:NGUYEN, THI
Entity Type:Individual
Prefix:
First Name:THI
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 1:4044 EAGLE ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-3608
Mailing Address - Country:US
Mailing Address - Phone:323-254-8642
Mailing Address - Fax:
Practice Address - Street 1:4044 EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-3608
Practice Address - Country:US
Practice Address - Phone:323-254-8642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist