Healthcare Provider Details

I. General information

NPI: 1326662958
Provider Name (Legal Business Name): LARRY NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 42ND AVE N
NEW HOPE MN
55427-1100
US

IV. Provider business mailing address

15210 RANGER RD
SAN LEANDRO CA
94579-2614
US

V. Phone/Fax

Practice location:
  • Phone: 763-531-7460
  • Fax:
Mailing address:
  • Phone: 510-912-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number124181
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: