=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124599477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LONG THANH NGUYEN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5037 E BRUNDAGE LN
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93307-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-448-8147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12202 ORA ST
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92840-3458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 79922
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------