Provider Demographics
NPI:1528669447
Name:NGUYEN, THAO PHUONG (PHARMD)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:PHUONG
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:PHUONG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12445 HEDGES RUN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1715
Mailing Address - Country:US
Mailing Address - Phone:703-491-7694
Mailing Address - Fax:844-411-8529
Practice Address - Street 1:12445 HEDGES RUN DR
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-1715
Practice Address - Country:US
Practice Address - Phone:703-491-7694
Practice Address - Fax:844-411-8529
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist