Provider Demographics
NPI:1700411238
Name:NGUYEN, MINH KHOA BA
Entity Type:Individual
Prefix:
First Name:MINH KHOA
Middle Name:BA
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 1:8936 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2742
Mailing Address - Country:US
Mailing Address - Phone:952-881-0163
Mailing Address - Fax:
Practice Address - Street 1:8936 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-2742
Practice Address - Country:US
Practice Address - Phone:952-881-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist