Healthcare Provider Details

I. General information

NPI: 1639448939
Provider Name (Legal Business Name): JEFFREY RATHAPONG THOONGSUWAN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

1412 SOMERSET DR
SAN DIMAS CA
91773-3841
US

V. Phone/Fax

Practice location:
  • Phone: 951-353-2620
  • Fax:
Mailing address:
  • Phone: 626-589-3920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number58655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: