Provider Demographics
NPI:1144822248
Name:NGUYEN, KIM LE
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:LE
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13051 GLENNWOOD PL
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2470
Mailing Address - Country:US
Mailing Address - Phone:228-547-7631
Mailing Address - Fax:
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-865-3252
Practice Address - Fax:228-867-5088
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist