Provider Demographics
NPI:1134471121
Name:PHAEN, SOTHEA (PHARM D)
Entity Type:Individual
Prefix:
First Name:SOTHEA
Middle Name:
Last Name:PHAEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 CHELMSFORD ST UNIT 15
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-2356
Mailing Address - Country:US
Mailing Address - Phone:978-853-0026
Mailing Address - Fax:
Practice Address - Street 1:1 GENERAL STREET
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01842
Practice Address - Country:US
Practice Address - Phone:978-683-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist