Provider Demographics
NPI:1134775729
Name:TRIEU, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:TRIEU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 NW STEWART PKWY, #304
Mailing Address - Street 2:PMB 216
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 SE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3136
Practice Address - Country:US
Practice Address - Phone:541-672-4896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-10
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist