Provider Demographics
NPI:1235316134
Name:TAM HOANG NGUYEN
Entity Type:Organization
Organization Name:TAM HOANG NGUYEN
Other - Org Name:MAI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAM
Authorized Official - Middle Name:HOANG
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-393-5961
Mailing Address - Street 1:7240 E SOUTHGATE DR
Mailing Address - Street 2:SUITE # A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2627
Mailing Address - Country:US
Mailing Address - Phone:916-393-5961
Mailing Address - Fax:
Practice Address - Street 1:7240 E SOUTHGATE DR
Practice Address - Street 2:SUITE # A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2627
Practice Address - Country:US
Practice Address - Phone:916-393-5961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY-378433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA378430Medicaid