Provider Demographics
NPI:1295916294
Name:NGUYEN, DOMINIQUE (BS PHARMACY)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1229
Mailing Address - Country:US
Mailing Address - Phone:516-621-2466
Mailing Address - Fax:516-621-5677
Practice Address - Street 1:1140 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-1229
Practice Address - Country:US
Practice Address - Phone:516-621-2466
Practice Address - Fax:516-621-5677
Is Sole Proprietor?:No
Enumeration Date:2007-11-18
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01017550Medicaid