Provider Demographics
NPI:1871197749
Name:NGUYEN, MAI THANH (PHARM D)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 LOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2459
Mailing Address - Country:US
Mailing Address - Phone:703-217-0674
Mailing Address - Fax:
Practice Address - Street 1:11003 LEE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5002
Practice Address - Country:US
Practice Address - Phone:571-432-5801
Practice Address - Fax:571-432-5807
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty