Provider Demographics
NPI:1881102630
Name:NGUYEN, KHANG
Entity type:Individual
Prefix:
First Name:KHANG
Middle Name:
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 1:17620 GLADESWORTH LN
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-3809
Mailing Address - Country:US
Mailing Address - Phone:818-269-0829
Mailing Address - Fax:
Practice Address - Street 1:1526 MISSION ST
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3216
Practice Address - Country:US
Practice Address - Phone:626-799-1414
Practice Address - Fax:626-799-1414
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist