Provider Demographics
NPI:1164759007
Name:KONGDARA, SIM T (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SIM
Middle Name:T
Last Name:KONGDARA
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 1:6204 LANDON DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6551
Mailing Address - Country:US
Mailing Address - Phone:806-352-0382
Mailing Address - Fax:
Practice Address - Street 1:5921 HILLSIDE RD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-6294
Practice Address - Country:US
Practice Address - Phone:806-463-1057
Practice Address - Fax:806-463-3256
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist