Provider Demographics
NPI:1164822821
Name:NGUYEN, LONG
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30491 AVENIDA DE LAS FLORES
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-3923
Mailing Address - Country:US
Mailing Address - Phone:949-207-5155
Mailing Address - Fax:949-207-5155
Practice Address - Street 1:30491 AVENIDA DE LAS FLORES
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-3923
Practice Address - Country:US
Practice Address - Phone:949-207-5155
Practice Address - Fax:949-207-5155
Is Sole Proprietor?:No
Enumeration Date:2014-09-01
Last Update Date:2014-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65120183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist