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General NPI Number Information
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NPI Number | 1740413426
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Entity Type | Individual
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Provider Name | KEO KEVIN VONGVICHITH PHARMD
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Gender | Male
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Dates
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Enumeration Date | 08/28/2009
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Last Update Date | 08/28/2009
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Provider Practice Location Address
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Address Line | 3632 MENAUL BLVD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-2851
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Country | US
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Telephone | 505-217-2551
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Fax | 505-217-2557
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Provider Business Mailing Address
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Address Line | 605 MARTHA ST NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87123-2926
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Country | US
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Telephone | 505-453-6121
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Fax | 505-217-2557
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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 | RP00006698
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License Number State | NM
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