Provider Demographics
NPI:1508392184
Name:TRAN, CUONG KIM
Entity Type:Individual
Prefix:MISS
First Name:CUONG
Middle Name:KIM
Last Name:TRAN
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 1:512 N GUADALUPE AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2951
Mailing Address - Country:US
Mailing Address - Phone:310-621-2915
Mailing Address - Fax:
Practice Address - Street 1:512 N GUADALUPE AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2951
Practice Address - Country:US
Practice Address - Phone:310-621-2915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63317183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist