Provider Demographics
NPI:1407494230
Name:PANTAYATIWONG, KAYE
Entity Type:Individual
Prefix:
First Name:KAYE
Middle Name:
Last Name:PANTAYATIWONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 E DALTON AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-2708
Mailing Address - Country:US
Mailing Address - Phone:626-616-0394
Mailing Address - Fax:
Practice Address - Street 1:130 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-2434
Practice Address - Country:US
Practice Address - Phone:626-963-0385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist