Provider Demographics
NPI:1326461120
Name:PHUNG, TRUONG
Entity Type:Individual
Prefix:
First Name:TRUONG
Middle Name:
Last Name:PHUNG
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 1:380 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3252
Mailing Address - Country:US
Mailing Address - Phone:946-645-1277
Mailing Address - Fax:949-645-4738
Practice Address - Street 1:25539 PASEO DE VALENCIA
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5348
Practice Address - Country:US
Practice Address - Phone:949-951-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13226183500000X
CACA48948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist