Provider Demographics
NPI:1801491295
Name:NGUYEN, KHANH TRUNG HA
Entity type:Individual
Prefix:
First Name:KHANH TRUNG
Middle Name:HA
Last Name:NGUYEN
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 1:1175 RIVER OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5498
Mailing Address - Country:US
Mailing Address - Phone:678-654-9118
Mailing Address - Fax:
Practice Address - Street 1:780 GLYNN ST N
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1193
Practice Address - Country:US
Practice Address - Phone:770-716-2262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist