Provider Demographics
NPI:1619496221
Name:PUNTUWONGSA, WARAWAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:WARAWAN
Middle Name:
Last Name:PUNTUWONGSA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6283 SANTANDER AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-2299
Mailing Address - Country:US
Mailing Address - Phone:702-324-4871
Mailing Address - Fax:
Practice Address - Street 1:1925 E ANDY DEVINE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-7101
Practice Address - Country:US
Practice Address - Phone:928-753-7766
Practice Address - Fax:928-753-7786
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS021143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist