Basic Information
| Provider Information | |||||||||
| NPI: | 1487102174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | KIM PHUONG | ||||||||
| MiddleName: | THI | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 CHABLIS CT | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302147120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048250989 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 132 OLD NORTON RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302154873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788171117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2016 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835X0200X | 025736 | GA | Y | Pharmacy Service Providers | Pharmacist | Oncology |
No ID Information.