Provider Demographics
NPI:1215214424
Name:NGUYEN, LY KHANH (RPH)
Entity Type:Individual
Prefix:
First Name:LY
Middle Name:KHANH
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 64TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-5316
Mailing Address - Country:US
Mailing Address - Phone:727-545-5069
Mailing Address - Fax:
Practice Address - Street 1:6996 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781
Practice Address - Country:US
Practice Address - Phone:727-528-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL38129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist