Provider Demographics
NPI:1417653239
Name:NGUYEN, NGOC BAO (RPH)
Entity Type:Individual
Prefix:
First Name:NGOC
Middle Name:BAO
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 S HUDSON AVE APT E104
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4256
Mailing Address - Country:US
Mailing Address - Phone:661-854-6432
Mailing Address - Fax:
Practice Address - Street 1:1515 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4039
Practice Address - Country:US
Practice Address - Phone:208-345-7684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist