Provider Demographics
NPI:1447563895
Name:NGHIEM, JASON BAO
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:BAO
Last Name:NGHIEM
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:THUY
Other - Middle Name:BAO
Other - Last Name:NGHIEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41463 ALEXO DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-2333
Mailing Address - Country:US
Mailing Address - Phone:714-932-7330
Mailing Address - Fax:
Practice Address - Street 1:2419 E AVENUE S
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-6202
Practice Address - Country:US
Practice Address - Phone:661-274-4333
Practice Address - Fax:661-274-8015
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist