Provider Demographics
NPI:1447242516
Name:NGUYEN, TAM HOANG
Entity Type:Individual
Prefix:
First Name:TAM
Middle Name:HOANG
Last Name:NGUYEN
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 1:7240 E SOUTHGATE DR
Mailing Address - Street 2:SUITE # A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2627
Mailing Address - Country:US
Mailing Address - Phone:916-393-5961
Mailing Address - Fax:
Practice Address - Street 1:7240 E SOUTHGATE DR
Practice Address - Street 2:SUITE # A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2627
Practice Address - Country:US
Practice Address - Phone:916-393-5961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA3784303336C0003X
CARPH42362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA378430Medicaid