Provider Demographics
NPI:1598361594
Name:HOMPUANGPHOO, SANTI
Entity Type:Individual
Prefix:
First Name:SANTI
Middle Name:
Last Name:HOMPUANGPHOO
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 1:3343 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1205
Mailing Address - Country:US
Mailing Address - Phone:773-279-2929
Mailing Address - Fax:773-279-2935
Practice Address - Street 1:3343 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1205
Practice Address - Country:US
Practice Address - Phone:773-279-2929
Practice Address - Fax:773-279-2935
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013080183500000X
HIPH3612183500000X
IL051286813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist