Provider Demographics
NPI:1376919183
Name:NGUYEN, AMADEUS (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMADEUS
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 S SAN JACINTO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5181
Mailing Address - Country:US
Mailing Address - Phone:951-654-4734
Mailing Address - Fax:
Practice Address - Street 1:1605 S SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5181
Practice Address - Country:US
Practice Address - Phone:951-654-4734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist