=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659954741
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANICE TRUC NGUYEN PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2021
-----------------------------------------------------
Last Update Date | 10/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4294 LAUREL DR
-----------------------------------------------------
City | LAKE ODESSA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48849-8430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-374-7660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2496 EDEN ST SW
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49519-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-881-1819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P2201X
-----------------------------------------------------
Taxonomy Name | Ambulatory Care Pharmacist
-----------------------------------------------------
License Number | 5302414668
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------