Provider Demographics
NPI:1184765315
Name:KONDO ENTERPRISES CORP
Entity type:Organization
Organization Name:KONDO ENTERPRISES CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST, PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:YAO
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDO
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:501-353-2136
Mailing Address - Street 1:11321 INTERSTATE 30
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-7040
Mailing Address - Country:US
Mailing Address - Phone:501-353-2136
Mailing Address - Fax:501-353-2594
Practice Address - Street 1:11321 INTERSTATE 30
Practice Address - Street 2:SUITE 102
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-7040
Practice Address - Country:US
Practice Address - Phone:501-353-2136
Practice Address - Fax:501-353-2594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0418649OtherNCPDP
AR126154407Medicaid