Healthcare Provider Details

I. General information

NPI: 1760764856
Provider Name (Legal Business Name): BIC T NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 301 N 21 B AVENUE
ZUNI NM
87327
US

IV. Provider business mailing address

215 MAPLE AVE
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-7518
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP442968
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007214
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: