Provider Demographics
NPI:1508471269
Name:SUBPHACHAISIRIKUL, KITTISAK (RPH)
Entity Type:Individual
Prefix:MR
First Name:KITTISAK
Middle Name:
Last Name:SUBPHACHAISIRIKUL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12315 WIPPLE TREE CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1756
Mailing Address - Country:US
Mailing Address - Phone:928-301-9196
Mailing Address - Fax:
Practice Address - Street 1:3569 FAR WEST BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3064
Practice Address - Country:US
Practice Address - Phone:512-345-2570
Practice Address - Fax:512-345-4222
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist