Provider Demographics
NPI:1184220253
Name:NGUYEN, QUOC BAO
Entity Type:Individual
Prefix:
First Name:QUOC
Middle Name:BAO
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 1:23208 FRONT BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-1012
Mailing Address - Country:US
Mailing Address - Phone:850-230-1434
Mailing Address - Fax:850-230-1435
Practice Address - Street 1:23208 FRONT BEACH RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-1012
Practice Address - Country:US
Practice Address - Phone:850-230-1434
Practice Address - Fax:850-230-1435
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist