Healthcare Provider Details

I. General information

NPI: 1275244113
Provider Name (Legal Business Name): KONGCHENG VAHCHUAMA PHARMD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/31/2022
Certification Date: 12/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12802 E 96TH ST N
OWASSO OK
74055-5371
US

IV. Provider business mailing address

11613 N 158TH EAST AVE
COLLINSVILLE OK
74021-5827
US

V. Phone/Fax

Practice location:
  • Phone: 918-272-7467
  • Fax:
Mailing address:
  • Phone: 916-719-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19919
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: