Provider Demographics
NPI:1053865089
Name:VUTH, VORLEAK
Entity Type:Individual
Prefix:
First Name:VORLEAK
Middle Name:
Last Name:VUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18980 HIGHSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-6171
Mailing Address - Country:US
Mailing Address - Phone:240-429-4868
Mailing Address - Fax:
Practice Address - Street 1:7165 COLUMBIA GATEWAY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2539
Practice Address - Country:US
Practice Address - Phone:410-290-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist