Provider Demographics
NPI:1326934498
Name:RAJAVONG, KEOMOUKDA (RPH)
Entity type:Individual
Prefix:
First Name:KEOMOUKDA
Middle Name:
Last Name:RAJAVONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 S 52ND ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3409
Mailing Address - Country:US
Mailing Address - Phone:215-471-4000
Mailing Address - Fax:215-471-4001
Practice Address - Street 1:1501 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-3319
Practice Address - Country:US
Practice Address - Phone:215-235-4000
Practice Address - Fax:267-324-5875
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039891L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist