Healthcare Provider Details

I. General information

NPI: 1992217582
Provider Name (Legal Business Name): KHOA DANG NGUYEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 07/04/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5108 CLEVELAND BLVD
CALDWELL ID
83607-8002
US

IV. Provider business mailing address

5108 CLEVELAND BLVD PHARMACY
CALDWELL ID
83607-8002
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-0800
  • Fax:
Mailing address:
  • Phone: 208-455-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0010180
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60786953
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25118
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0016238
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7869
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number214888
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: