Provider Demographics
NPI:1962002022
Name:NGUYEN, THU MONG
Entity Type:Individual
Prefix:
First Name:THU
Middle Name:MONG
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 1:2804 STADIUM VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-2023
Mailing Address - Country:US
Mailing Address - Phone:214-769-6396
Mailing Address - Fax:
Practice Address - Street 1:8401 ANDERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-3857
Practice Address - Country:US
Practice Address - Phone:817-276-9041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist