Healthcare Provider Details

I. General information

NPI: 1417119074
Provider Name (Legal Business Name): REX SOUMPHOLPHAKDY PHARMD., RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 COORS BLVD NW
ALBUQUERQUE NM
87120-2785
US

IV. Provider business mailing address

6200 COORS BLVD NW
ALBUQUERQUE NM
87120-2785
US

V. Phone/Fax

Practice location:
  • Phone: 505-898-5970
  • Fax: 505-792-5198
Mailing address:
  • Phone: 505-898-5970
  • Fax: 505-792-5198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number82-0184434
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: