Provider Demographics
NPI:1760891675
Name:NGUYEN, KHANH
Entity Type:Individual
Prefix:
First Name:KHANH
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 1:403 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:WAVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39576-2507
Mailing Address - Country:US
Mailing Address - Phone:228-467-9247
Mailing Address - Fax:228-467-4207
Practice Address - Street 1:403 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:WAVELAND
Practice Address - State:MS
Practice Address - Zip Code:39576-2507
Practice Address - Country:US
Practice Address - Phone:228-467-9247
Practice Address - Fax:228-467-4207
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-13543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist