Provider Demographics
NPI:1104393768
Name:NGUYEN, TAM THANH
Entity Type:Individual
Prefix:
First Name:TAM
Middle Name:THANH
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 1:1060 THORNHILL LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-3292
Mailing Address - Country:US
Mailing Address - Phone:916-273-0692
Mailing Address - Fax:
Practice Address - Street 1:9340 DESCHUTES RD
Practice Address - Street 2:
Practice Address - City:PALO CEDRO
Practice Address - State:CA
Practice Address - Zip Code:96073-9763
Practice Address - Country:US
Practice Address - Phone:530-547-4403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79817183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist