Healthcare Provider Details

I. General information

NPI: 1598220113
Provider Name (Legal Business Name): NGAN NGOCKIM DAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date: 05/09/2019
Reactivation Date: 05/15/2019

III. Provider practice location address

5877 CERVANTES AVE
SAN DIEGO CA
92114-6538
US

IV. Provider business mailing address

5877 CERVANTES AVE
SAN DIEGO CA
92114-6538
US

V. Phone/Fax

Practice location:
  • Phone: 714-383-5808
  • Fax:
Mailing address:
  • Phone: 714-383-5808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number80127
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number80127
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: