Provider Demographics
NPI:1619577731
Name:LUU, KIET KHANH
Entity Type:Individual
Prefix:
First Name:KIET
Middle Name:KHANH
Last Name:LUU
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 1:7373 VALLEY VIEW LN APT 3060
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-5572
Mailing Address - Country:US
Mailing Address - Phone:972-741-0211
Mailing Address - Fax:
Practice Address - Street 1:8801 HIGHWAY 34 S
Practice Address - Street 2:
Practice Address - City:QUINLAN
Practice Address - State:TX
Practice Address - Zip Code:75474-9434
Practice Address - Country:US
Practice Address - Phone:903-356-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist