Provider Demographics
NPI:1578991204
Name:CAO, ANDY NGUYEN
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:NGUYEN
Last Name:CAO
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 1:4545 GEORGETOWN PL STE B10
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6230
Mailing Address - Country:US
Mailing Address - Phone:209-851-2162
Mailing Address - Fax:209-851-2935
Practice Address - Street 1:4545 GEORGETOWN PL STE B10
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6230
Practice Address - Country:US
Practice Address - Phone:209-851-2162
Practice Address - Fax:209-851-2935
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 68577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist