Healthcare Provider Details

I. General information

NPI: 1710895214
Provider Name (Legal Business Name): HIEU HUYNH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 W KETTLEMAN LN
LODI CA
95242-4124
US

IV. Provider business mailing address

10199 RIVER PARK CIR
STOCKTON CA
95209-4182
US

V. Phone/Fax

Practice location:
  • Phone: 209-367-7882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number92920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: