1679373237 NPI number — 6574BRAVO LLC

Table of content: MYLINH NGUYEN PHARM D. (NPI 1326481136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679373237 NPI number — 6574BRAVO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
6574BRAVO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679373237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 OLD FARM RD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72601-8629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-577-3135
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 HIGHWAY 62 65 N STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72601-1959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-416-5555
Provider Business Practice Location Address Fax Number:
870-416-3990
Provider Enumeration Date:
03/13/2025

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHY
Authorized Official First Name:
JONI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
870-416-3555

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)