=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245998996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATTANA TINA KETTAVONG PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2021
-----------------------------------------------------
Last Update Date | 11/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 218 E MAIN ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06413-2230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-664-4641
-----------------------------------------------------
Fax | 860-664-1632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 92 STONEGATE RD
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06053-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-830-2122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PCT.0015656
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------