Provider Demographics
NPI:1659654903
Name:LISTON, SOMSAVAI KEODARA (RPH)
Entity Type:Individual
Prefix:
First Name:SOMSAVAI
Middle Name:KEODARA
Last Name:LISTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6574 FENCE JUMPER AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-0222
Mailing Address - Country:US
Mailing Address - Phone:702-396-0394
Mailing Address - Fax:
Practice Address - Street 1:6825 N DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4594
Practice Address - Country:US
Practice Address - Phone:702-260-8242
Practice Address - Fax:702-260-7225
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15771183500000X
CA54056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist