Provider Demographics
NPI:1750772182
Name:DOUANGPHACHANH, VONGPADITH (PHARMD)
Entity type:Individual
Prefix:
First Name:VONGPADITH
Middle Name:
Last Name:DOUANGPHACHANH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3918
Mailing Address - Country:US
Mailing Address - Phone:920-469-3436
Mailing Address - Fax:920-469-3568
Practice Address - Street 1:1819 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3918
Practice Address - Country:US
Practice Address - Phone:920-469-3436
Practice Address - Fax:920-469-3568
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16601-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist