Healthcare Provider Details

I. General information

NPI: 1871301812
Provider Name (Legal Business Name): KAYLA PHENGMANIVANH RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 N MEDICAL CENTER DR W STE 203
CLOVIS CA
93611-6878
US

IV. Provider business mailing address

7447 N 5TH ST
FRESNO CA
93720-2508
US

V. Phone/Fax

Practice location:
  • Phone: 559-387-1900
  • Fax:
Mailing address:
  • Phone: 559-286-7901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number90604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: