Healthcare Provider Details

I. General information

NPI: 1104477256
Provider Name (Legal Business Name): PETER KHONG PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 US-190
MANDEVILLE LA
70461
US

IV. Provider business mailing address

1121 WYNDHAM S
GRETNA LA
70056-8371
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-8106
  • Fax:
Mailing address:
  • Phone: 402-913-7437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number023215
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: