Provider Demographics
NPI:1497146625
Name:SIHAVONG, BOUNNHOU BON (PHARMD)
Entity Type:Individual
Prefix:
First Name:BOUNNHOU
Middle Name:BON
Last Name:SIHAVONG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:BON
Other - Middle Name:
Other - Last Name:SIHAVONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:PO BOX 230969
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-0969
Mailing Address - Country:US
Mailing Address - Phone:800-330-3665
Mailing Address - Fax:800-982-2730
Practice Address - Street 1:16100 SW 72ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-7745
Practice Address - Country:US
Practice Address - Phone:800-330-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0014294183500000X
WAPH 60504941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist