Healthcare Provider Details

I. General information

NPI: 1821371840
Provider Name (Legal Business Name): BRIAN TIEU PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80B VETERANS BLVD
ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5457
  • Fax: 505-552-5464
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number65284
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH-3136
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: