Provider Demographics
NPI:1417366485
Name:NGUYEN, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8971 MARY HILL DR
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4667
Mailing Address - Country:US
Mailing Address - Phone:714-366-1308
Mailing Address - Fax:
Practice Address - Street 1:13331 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-9206
Practice Address - Country:US
Practice Address - Phone:714-799-0039
Practice Address - Fax:714-799-0069
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist