Healthcare Provider Details

I. General information

NPI: 1174781991
Provider Name (Legal Business Name): THAO PHUONG NGUYEN PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16491 LAKESHORE DR
LAKE ELSINORE CA
92530
US

IV. Provider business mailing address

4544 MEREDITH ST
RIVERSIDE CA
92505-1537
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-0309
  • Fax: 951-674-0419
Mailing address:
  • Phone: 714-873-2438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: