Provider Demographics
NPI:1609112234
Name:VONGSOUVANH, AMMATA (PHARM D)
Entity Type:Individual
Prefix:
First Name:AMMATA
Middle Name:
Last Name:VONGSOUVANH
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15995 SW WALKER RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4910
Mailing Address - Country:US
Mailing Address - Phone:503-690-5833
Mailing Address - Fax:503-690-5827
Practice Address - Street 1:15995 SW WALKER RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4910
Practice Address - Country:US
Practice Address - Phone:503-690-5833
Practice Address - Fax:503-690-5827
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0011789183500000X
ORRPH-00117891835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist