Provider Demographics
NPI:1225105679
Name:LE, QUOC QUANG
Entity Type:Individual
Prefix:
First Name:QUOC
Middle Name:QUANG
Last Name:LE
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 1:3610 W 1ST ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-3315
Mailing Address - Country:US
Mailing Address - Phone:714-839-7393
Mailing Address - Fax:714-839-7498
Practice Address - Street 1:3610 W 1ST ST
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-3315
Practice Address - Country:US
Practice Address - Phone:714-839-7393
Practice Address - Fax:714-839-7498
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
562923OtherNABP NUMBER
CA412660Medicaid
562923OtherNABP NUMBER