Provider Demographics
NPI:1811403603
Name:BOULOM, HIEU THI THANH NGUYEN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:HIEU
Middle Name:THI THANH NGUYEN
Last Name:BOULOM
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:HIEU
Other - Middle Name:THI THANH
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1810 FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:WATSONVIEW
Mailing Address - State:CA
Mailing Address - Zip Code:95076
Mailing Address - Country:US
Mailing Address - Phone:831-766-0183
Mailing Address - Fax:
Practice Address - Street 1:2810 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:WATSONVIEW
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:831-766-0183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-16
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist