Provider Demographics
NPI:1225373715
Name:NGO, NGOCYEN THI (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:NGOCYEN
Middle Name:THI
Last Name:NGO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3621
Mailing Address - Country:US
Mailing Address - Phone:309-685-2012
Mailing Address - Fax:309-685-1726
Practice Address - Street 1:2515 N KNOXVILLE AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604
Practice Address - Country:US
Practice Address - Phone:309-685-2012
Practice Address - Fax:309-685-1726
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296261183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist