Healthcare Provider Details

I. General information

NPI: 1699699504
Provider Name (Legal Business Name): KELLY THUVAMONTOLRAT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 BROOKSHIRE AVE
DOWNEY CA
90241-4917
US

IV. Provider business mailing address

14424 DENLEY ST
HACIENDA HEIGHTS CA
91745-1909
US

V. Phone/Fax

Practice location:
  • Phone: 562-904-5511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number68103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: