=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942719232
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THIEN C NGUYEN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2017
-----------------------------------------------------
Last Update Date | 09/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2825 RYAN ST
-----------------------------------------------------
City | LAKE CHARLES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70601-7329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-494-1590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1347 AVIATORS ST
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70122-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-756-5691
-----------------------------------------------------
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 | PST.022166
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | PST.022166
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------