Healthcare Provider Details

I. General information

NPI: 1144930843
Provider Name (Legal Business Name): KETFA INTHATHIRATH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28635 N NORTH VALLEY PKWY
PHOENIX AZ
85085-5434
US

IV. Provider business mailing address

24250 N 23RD AVE UNIT 3188
PHOENIX AZ
85085-1990
US

V. Phone/Fax

Practice location:
  • Phone: 623-582-9207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS026228
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: