Provider Demographics
NPI:1548998529
Name:VAN, NGOCTUYEN T
Entity type:Individual
Prefix:
First Name:NGOCTUYEN
Middle Name:T
Last Name:VAN
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 1:10112 65TH DR NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2431
Mailing Address - Country:US
Mailing Address - Phone:425-232-8837
Mailing Address - Fax:
Practice Address - Street 1:9925 STATE AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-2253
Practice Address - Country:US
Practice Address - Phone:425-232-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61312003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist