Provider Demographics
NPI:1366512287
Name:CHANVITAYAPONGS, KRILURK (RPH)
Entity type:Individual
Prefix:
First Name:KRILURK
Middle Name:
Last Name:CHANVITAYAPONGS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 SOUTH WARD
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830
Mailing Address - Country:US
Mailing Address - Phone:800-626-6934
Mailing Address - Fax:573-333-2843
Practice Address - Street 1:2709 SOUTH WARD
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830
Practice Address - Country:US
Practice Address - Phone:800-626-6934
Practice Address - Fax:573-333-2843
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist