Provider Demographics
NPI:1730457862
Name:NGUYEN, JUSTINE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
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 1:1101 VISTA LOMAS LN
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3632
Mailing Address - Country:US
Mailing Address - Phone:714-906-2342
Mailing Address - Fax:
Practice Address - Street 1:128 S STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2921
Practice Address - Country:US
Practice Address - Phone:714-778-2519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-04
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist