Provider Demographics
NPI:1073868196
Name:SOURIYAVONG, BOUNCHANH (PHARMD)
Entity Type:Individual
Prefix:
First Name:BOUNCHANH
Middle Name:
Last Name:SOURIYAVONG
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 1:2804 BRIGHTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-5821
Mailing Address - Country:US
Mailing Address - Phone:615-585-6642
Mailing Address - Fax:
Practice Address - Street 1:1211 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0004
Practice Address - Country:US
Practice Address - Phone:615-343-0608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-14
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist