Provider Demographics
NPI:1407445364
Name:HOANG, PHUOC THO
Entity Type:Individual
Prefix:
First Name:PHUOC
Middle Name:THO
Last Name:HOANG
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 1:1590 LAWREN LN
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1556
Mailing Address - Country:US
Mailing Address - Phone:909-264-5933
Mailing Address - Fax:
Practice Address - Street 1:1033 N WATERMAN AVE STE C
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3808
Practice Address - Country:US
Practice Address - Phone:909-884-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH83545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist