MEDICARE: SUSAN NGUYEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	66470	CA

General Provider Information

NPI Number	:	1316224090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN NGUYEN

Provider Business Mailing Address
First Line	:	747 GRAND AVE
Second Line	:	T-2179
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-8400
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	747 GRAND AVE
Second Line	:	T-2179
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-8400
Country	:	US
Telephone Number	:	909-610-2150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2011
Last Update Date	:	11/09/2011

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