MEDICARE: DR. CHICKHAM SYVANTHONG PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	16890	NC

General Provider Information

NPI Number	:	1033412556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHICKHAM SYVANTHONG PHARM.D.

Provider Business Mailing Address
First Line	:	8220 MOUNT HOLLY HUNTERSVILLE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-9744
Country	:	US
Telephone Number	:	704-399-5303
Fax Number	:

Provider Business Practice Location Address
First Line	:	8220 MOUNT HOLLY HUNTERSVILLE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-9744
Country	:	US
Telephone Number	:	704-399-5303
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	12/07/2010

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