Provider Demographics
NPI:1306396502
Name:DINH, PETER TUONG
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:TUONG
Last Name:DINH
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:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:MIDWAY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92655-0554
Mailing Address - Country:US
Mailing Address - Phone:714-482-3062
Mailing Address - Fax:
Practice Address - Street 1:233 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2623
Practice Address - Country:US
Practice Address - Phone:714-482-3062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1043252232Medicaid