Provider Demographics
NPI:1659977536
Name:NGUYEN, DIANA KIM
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:KIM
Last Name:NGUYEN
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 1:1942 SQUIREWOOD DR E
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-7489
Mailing Address - Country:US
Mailing Address - Phone:850-529-3029
Mailing Address - Fax:
Practice Address - Street 1:4600 WESTBANK EXPY
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3065
Practice Address - Country:US
Practice Address - Phone:504-340-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.0236283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy