Basic Information
| Provider Information | |||||||||
| NPI: | 1487193728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | JANNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14305 MERIDIAN PKWY | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925183034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512517520 | ||||||||
| FaxNumber: | 9512517502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2017 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 56689 | CA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 1487193728 | 01 | CA | PHARMACIST | OTHER |