Provider Demographics
NPI:1649921412
Name:VAN, NGON-VINCENT (PHARMD)
Entity type:Individual
Prefix:
First Name:NGON-VINCENT
Middle Name:
Last Name:VAN
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 NE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3260
Mailing Address - Country:US
Mailing Address - Phone:870-656-2420
Mailing Address - Fax:
Practice Address - Street 1:10913 NW 30TH ST STE 102
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-5029
Practice Address - Country:US
Practice Address - Phone:888-648-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist