Provider Demographics
NPI:1326354879
Name:KANTAM, VIJAY S
Entity Type:Individual
Prefix:MR
First Name:VIJAY
Middle Name:S
Last Name:KANTAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2755 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5913
Practice Address - Country:US
Practice Address - Phone:337-477-7564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-22
Last Update Date:2010-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist