Healthcare Provider Details

I. General information

NPI: 1437694171
Provider Name (Legal Business Name): NATALIE SOMBOONSOOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 09/09/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18880 CHERRY VALLEY BLVD
TUOLUMNE CA
95379-9506
US

IV. Provider business mailing address

18880 CHERRY VALLEY BLVD
TUOLUMNE CA
95379-9506
US

V. Phone/Fax

Practice location:
  • Phone: 209-928-5407
  • Fax:
Mailing address:
  • Phone: 209-928-5407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number72678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: