Provider Demographics
NPI:1821764606
Name:NGUYEN, NIKKI LU THANH THAO
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:LU THANH THAO
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 1:50 CASTLETREE
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-5506
Mailing Address - Country:US
Mailing Address - Phone:949-350-1937
Mailing Address - Fax:
Practice Address - Street 1:102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5259
Practice Address - Country:US
Practice Address - Phone:714-543-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84898183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist