Provider Demographics
NPI:1295346146
Name:NGUYEN, PHUONG T (PHARMD)
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:T
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4817 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2503
Mailing Address - Country:US
Mailing Address - Phone:773-889-7411
Mailing Address - Fax:773-889-4631
Practice Address - Street 1:4817 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2503
Practice Address - Country:US
Practice Address - Phone:773-889-7411
Practice Address - Fax:773-889-4631
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051301606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist