Provider Demographics
NPI:1679851653
Name:NGUYEN, MAILAN
Entity type:Individual
Prefix:
First Name:MAILAN
Middle Name:
Last Name:NGUYEN
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 1:695 W HERNDON AVE
Mailing Address - Street 2:T2018
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0104
Mailing Address - Country:US
Mailing Address - Phone:559-321-0010
Mailing Address - Fax:559-326-1351
Practice Address - Street 1:695 W HERNDON AVE
Practice Address - Street 2:T2018
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0104
Practice Address - Country:US
Practice Address - Phone:559-321-0010
Practice Address - Fax:559-326-1351
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist