Healthcare Provider Details

I. General information

NPI: 1740413426
Provider Name (Legal Business Name): KEO KEVIN VONGVICHITH PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEOMANY VONGVICHITH

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3632 MENAUL BLVD NE
ALBUQUERQUE NM
87110-2851
US

IV. Provider business mailing address

605 MARTHA ST NE
ALBUQUERQUE NM
87123-2926
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-2551
  • Fax: 505-217-2557
Mailing address:
  • Phone: 505-453-6121
  • Fax: 505-217-2557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006698
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: