Basic Information
| Provider Information | |||||||||
| NPI: | 1235778523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | |||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 850 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2020 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH23955 | MA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 111111111111 | 01 | MA | N/A | OTHER |