Provider Demographics
NPI:1295388593
Name:KHEUAKHAM, VILAILACK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:VILAILACK
Middle Name:
Last Name:KHEUAKHAM
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 1:1605 E BELL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50320-1135
Mailing Address - Country:US
Mailing Address - Phone:515-822-3969
Mailing Address - Fax:
Practice Address - Street 1:3600 30TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5753
Practice Address - Country:US
Practice Address - Phone:515-699-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist