Provider Demographics
NPI:1205378965
Name:BACCAM, LAVANH (PHARMD)
Entity Type:Individual
Prefix:
First Name:LAVANH
Middle Name:
Last Name:BACCAM
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 1:4121 FLEUR DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-2301
Mailing Address - Country:US
Mailing Address - Phone:515-285-5927
Mailing Address - Fax:515-285-8974
Practice Address - Street 1:4121 FLEUR DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-2301
Practice Address - Country:US
Practice Address - Phone:515-285-5927
Practice Address - Fax:515-285-8974
Is Sole Proprietor?:No
Enumeration Date:2016-11-12
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist