Provider Demographics
NPI:1326513789
Name:NGHIEM, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:NGHIEM
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 1:3136 BORGATA WAY
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-5436
Mailing Address - Country:US
Mailing Address - Phone:916-342-4856
Mailing Address - Fax:
Practice Address - Street 1:4400 LATROBE RD
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-6704
Practice Address - Country:US
Practice Address - Phone:916-934-0133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty