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General NPI Number Information
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NPI Number | 1467319202
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Entity Type | Individual
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Provider Name | SOPHANAROTH PENH
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Gender | Male
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Dates
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Enumeration Date | 01/05/2026
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Last Update Date | 01/05/2026
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Provider Practice Location Address
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Address Line | 71 BOXWOOD ST
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City | WILLISTON
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State | VT
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Zip | 05495-8211
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Country | US
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Telephone | 802-878-9056
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Fax |
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Provider Business Mailing Address
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Address Line | 11 PARK ST UNIT 415
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City | ESSEX JUNCTION
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State | VT
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Zip | 05452-4175
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 033.0135925
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License Number State | VT
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PH1002621
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License Number State | MA
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