Provider Demographics
NPI:1770209686
Name:TRIEU-DIMACULANGAN, ANGEL
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:TRIEU-DIMACULANGAN
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 1:13508 RYAN MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-1249
Mailing Address - Country:US
Mailing Address - Phone:713-423-9290
Mailing Address - Fax:
Practice Address - Street 1:5425 W US HWY 290 SERVICE ROAD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735
Practice Address - Country:US
Practice Address - Phone:512-654-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX515341835P0018X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist