Provider Demographics
NPI:1457945891
Name:NGUYEN, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
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 1:1058 S FEDERAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-4102
Mailing Address - Country:US
Mailing Address - Phone:303-975-1700
Mailing Address - Fax:303-975-1799
Practice Address - Street 1:1058 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-4102
Practice Address - Country:US
Practice Address - Phone:303-975-1700
Practice Address - Fax:303-975-1799
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36773841Medicaid