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General NPI Number Information
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NPI Number | 1942619820
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Entity Type | Individual
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Provider Name | THEVI PHANTHALANGSY
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Gender | Female
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Dates
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Enumeration Date | 08/05/2014
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Last Update Date | 08/05/2014
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Provider Practice Location Address
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Address Line | 1421 COFFEE ROAD
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City | MODESTO
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State | CA
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Zip | 95307
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Country | US
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Telephone | 209-222-5616
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Fax |
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Provider Business Mailing Address
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Address Line | 1421 COFFEE ROAD
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City | MODESTO
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State | CA
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Zip | 95307
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Country | US
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Telephone | 209-222-5616
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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 | 68229
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License Number State | CA
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