Healthcare Provider Details

I. General information

NPI: 1053283119
Provider Name (Legal Business Name): DR. THAVORY SOKON SAMOEUN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 FREMONT AVE
SAINT AUGUSTINE FL
32095-8646
US

IV. Provider business mailing address

22 FREMONT AVE
SAINT AUGUSTINE FL
32095-8646
US

V. Phone/Fax

Practice location:
  • Phone: 904-412-6549
  • Fax:
Mailing address:
  • Phone: 904-412-6549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number42516
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: