Provider Demographics
NPI:1417119074
Name:SOUMPHOLPHAKDY, REX (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:REX
Middle Name:
Last Name:SOUMPHOLPHAKDY
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 COORS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2785
Mailing Address - Country:US
Mailing Address - Phone:505-898-5970
Mailing Address - Fax:505-792-5198
Practice Address - Street 1:6200 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2785
Practice Address - Country:US
Practice Address - Phone:505-898-5970
Practice Address - Fax:505-792-5198
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-0184434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57358761Medicaid