Provider Demographics
NPI:1417552332
Name:BUTH, CHANTHY
Entity Type:Individual
Prefix:
First Name:CHANTHY
Middle Name:
Last Name:BUTH
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 1:4505 SEA SPARROW LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-2679
Mailing Address - Country:US
Mailing Address - Phone:209-670-4266
Mailing Address - Fax:
Practice Address - Street 1:1372 BELT LINE RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3266
Practice Address - Country:US
Practice Address - Phone:972-495-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist