Provider Demographics
NPI:1548715469
Name:NGUYEN, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHI
Other - Middle Name:K
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2055 N PERRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2509
Mailing Address - Country:US
Mailing Address - Phone:951-943-8188
Mailing Address - Fax:951-943-8199
Practice Address - Street 1:30251 MURRIETA RD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-8385
Practice Address - Country:US
Practice Address - Phone:951-244-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80320183500000X
ORPI-0012247390200000X
CAINT-37517390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program