Provider Demographics
NPI:1851577860
Name:DUONG, LAN NGOC
Entity Type:Individual
Prefix:
First Name:LAN
Middle Name:NGOC
Last Name:DUONG
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 1:6002 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3538
Mailing Address - Country:US
Mailing Address - Phone:718-476-8379
Mailing Address - Fax:718-476-8507
Practice Address - Street 1:6002 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3538
Practice Address - Country:US
Practice Address - Phone:718-476-8379
Practice Address - Fax:718-476-8507
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050978183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848608Medicaid