Provider Demographics
NPI:1447503735
Name:CHANTHAPHAVONG, SOUPHIDA KEKO (PHARMD)
Entity type:Individual
Prefix:
First Name:SOUPHIDA
Middle Name:KEKO
Last Name:CHANTHAPHAVONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9268 CHAMBERLAYNE RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2806
Mailing Address - Country:US
Mailing Address - Phone:804-746-4347
Mailing Address - Fax:
Practice Address - Street 1:9268 CHAMBERLAYNE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2806
Practice Address - Country:US
Practice Address - Phone:804-746-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist