=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184765315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KONDO ENTERPRISES CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 04/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11321 INTERSTATE 30 SUITE 102
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72209-7040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-353-2136
-----------------------------------------------------
Fax | 501-353-2594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11321 INTERSTATE 30 SUITE 102
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72209-7040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-353-2136
-----------------------------------------------------
Fax | 501-353-2594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST, PRESIDENT, CEO
-----------------------------------------------------
Name | DR. YAO KONDO
-----------------------------------------------------
Credential | P.D.
-----------------------------------------------------
Telephone | 501-353-2136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD08105
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------