Basic Information
| Provider Information | |||||||||
| NPI: | 1942691415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUONG | ||||||||
| FirstName: | GAI | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720A MEDICAL PARK DR | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395322129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282077716 | ||||||||
| FaxNumber: | 2282079598 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720A MEDICAL PARK DR | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395322129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282077716 | ||||||||
| FaxNumber: | 2282079598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2015 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | P09598 | MS | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 06972060 | 05 | MS | MEDICAID |