Provider Demographics
NPI:1568977155
Name:LE, MAI NGOC
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:NGOC
Last Name:LE
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 1:180 S LEXINGTON DR APT 1021
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-7016
Mailing Address - Country:US
Mailing Address - Phone:802-309-4955
Mailing Address - Fax:
Practice Address - Street 1:180 S LEXINGTON DR APT 1021
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-7016
Practice Address - Country:US
Practice Address - Phone:802-309-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2018-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist