=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871802868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QUANG BUU TRUONG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 09/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6710 W BETHANY HOME RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85303-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-934-9243
-----------------------------------------------------
Fax | 623-934-3692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 264
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-0090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-328-8148
-----------------------------------------------------
Fax | 623-934-3692
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S013954
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------