Provider Demographics
NPI:1578847364
Name:TRUONG, JOHN VAN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:VAN
Last Name:TRUONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3212
Mailing Address - Country:US
Mailing Address - Phone:617-427-1763
Mailing Address - Fax:
Practice Address - Street 1:2275 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-3212
Practice Address - Country:US
Practice Address - Phone:617-427-1763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist