Healthcare Provider Details

I. General information

NPI: 1295388593
Provider Name (Legal Business Name): VILAILACK KHEUAKHAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 30TH ST
DES MOINES IA
50310-5753
US

IV. Provider business mailing address

1605 E BELL AVE
DES MOINES IA
50320-1135
US

V. Phone/Fax

Practice location:
  • Phone: 515-699-5999
  • Fax:
Mailing address:
  • Phone: 515-822-3969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23405
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: