Healthcare Provider Details

I. General information

NPI: 1750772182
Provider Name (Legal Business Name): VONGPADITH DOUANGPHACHANH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 N GREEN BAY RD
BROWN DEER WI
53209-1104
US

IV. Provider business mailing address

1819 MAIN ST
GREEN BAY WI
54302-3918
US

V. Phone/Fax

Practice location:
  • Phone: 414-354-7213
  • Fax: 414-354-7932
Mailing address:
  • Phone: 920-469-3436
  • Fax: 920-469-3568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16601-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: