Provider Demographics
NPI:1689095317
Name:NGUYEN, QUANG
Entity Type:Individual
Prefix:DR
First Name:QUANG
Middle Name:
Last Name:NGUYEN
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 1:25691 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-3305
Mailing Address - Country:US
Mailing Address - Phone:503-667-9003
Mailing Address - Fax:
Practice Address - Street 1:25691 SE STARK ST
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-3305
Practice Address - Country:US
Practice Address - Phone:503-667-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-24
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORORRPH-0014227183500000X, 1835P0018X
ORPI-0010980390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCV11755CMedicaid