Healthcare Provider Details

I. General information

NPI: 1295379394
Provider Name (Legal Business Name): THAI VUONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 HIDDEN HOLLOW TER
PALM BEACH GARDENS FL
33418-6001
US

IV. Provider business mailing address

138 HIDDEN HOLLOW TER
PALM BEACH GARDENS FL
33418-6001
US

V. Phone/Fax

Practice location:
  • Phone: 408-799-5380
  • Fax:
Mailing address:
  • Phone: 408-799-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS52417
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: