Provider Demographics
NPI:1568752905
Name:NGUYEN, PHONG THANH (RPH)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 FARMSTEAD LN
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-1245
Mailing Address - Country:US
Mailing Address - Phone:860-758-7775
Mailing Address - Fax:
Practice Address - Street 1:99 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2550
Practice Address - Country:US
Practice Address - Phone:413-737-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH25227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist