Healthcare Provider Details

I. General information

NPI: 1962019174
Provider Name (Legal Business Name): BLAKE TRAN NUGEN PHARMD., R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 PARK AVE
PLAINFIELD NJ
07060-1612
US

IV. Provider business mailing address

408 WALL ST
EATONTOWN NJ
07724-2422
US

V. Phone/Fax

Practice location:
  • Phone: 908-756-0008
  • Fax: 908-668-8630
Mailing address:
  • Phone: 973-362-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04105200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: