Provider Demographics
NPI:1295379394
Name:VUONG, THAI
Entity Type:Individual
Prefix:
First Name:THAI
Middle Name:
Last Name:VUONG
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 1:138 HIDDEN HOLLOW TER
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-6001
Mailing Address - Country:US
Mailing Address - Phone:408-799-5380
Mailing Address - Fax:
Practice Address - Street 1:138 HIDDEN HOLLOW TER
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-6001
Practice Address - Country:US
Practice Address - Phone:408-799-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52417183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1381983Medicaid