Provider Demographics
NPI:1083885354
Name:TRUONG, ETHAN VAN (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:VAN
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 1:3130 GREYLING DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2940
Mailing Address - Country:US
Mailing Address - Phone:619-221-6275
Mailing Address - Fax:619-221-6489
Practice Address - Street 1:3250 FORDHAM ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5339
Practice Address - Country:US
Practice Address - Phone:858-221-6275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH57434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist