Provider Demographics
NPI:1558642942
Name:NGUYEN, MYA THAO
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:THAO
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 1:921 LARAMIE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3350
Mailing Address - Country:US
Mailing Address - Phone:708-369-3386
Mailing Address - Fax:
Practice Address - Street 1:4850 OAKTON ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2953
Practice Address - Country:US
Practice Address - Phone:847-933-0418
Practice Address - Fax:847-933-0418
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291588183500000X
IL051-291588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist