Provider Demographics
NPI:1609470988
Name:TRAN, TRUNG TRONG
Entity Type:Individual
Prefix:
First Name:TRUNG
Middle Name:TRONG
Last Name:TRAN
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 1:3101 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4413
Mailing Address - Country:US
Mailing Address - Phone:773-477-3333
Mailing Address - Fax:
Practice Address - Street 1:3101 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4413
Practice Address - Country:US
Practice Address - Phone:773-477-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist