Provider Demographics
NPI:1265036545
Name:NGUYEN, PHUONG KHANH
Entity Type:Individual
Prefix:
First Name:PHUONG KHANH
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12381 W BELLFORT ST
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-1312
Mailing Address - Country:US
Mailing Address - Phone:281-776-3070
Mailing Address - Fax:
Practice Address - Street 1:12381 W BELLFORT ST
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-1312
Practice Address - Country:US
Practice Address - Phone:281-776-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist