MEDICARE: ALAN DT NGUYEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	57102	TX

General Provider Information

NPI Number	:	1104437839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALAN DT NGUYEN

Provider Business Mailing Address
First Line	:	2510 MILL PLACE RD
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-4989
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3614 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3352
Country	:	US
Telephone Number	:	817-870-1873
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2020
Last Update Date	:	08/15/2020

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