Provider Demographics
NPI:1437677929
Name:SAVATPHONH, PHOUTHAVANH
Entity Type:Individual
Prefix:
First Name:PHOUTHAVANH
Middle Name:
Last Name:SAVATPHONH
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 1:200 HOLLAND DR # M1238
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-2545
Mailing Address - Country:US
Mailing Address - Phone:615-299-6563
Mailing Address - Fax:
Practice Address - Street 1:498 WARFIELD BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6071
Practice Address - Country:US
Practice Address - Phone:931-551-4290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41394183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist