Provider Demographics
NPI:1619568391
Name:NGUYEN, KEVIN ANH VU LE
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANH VU LE
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 E LITTLE DR
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5268
Mailing Address - Country:US
Mailing Address - Phone:714-616-6954
Mailing Address - Fax:
Practice Address - Street 1:200 FREEDOM LN
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5876
Practice Address - Country:US
Practice Address - Phone:949-900-8437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist