Provider Demographics
NPI:1659969491
Name:PATTERSON, VIENGKHAM
Entity Type:Individual
Prefix:
First Name:VIENGKHAM
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CORINTH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3087
Mailing Address - Country:US
Mailing Address - Phone:617-323-6544
Mailing Address - Fax:617-469-5627
Practice Address - Street 1:1 CORINTH ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3087
Practice Address - Country:US
Practice Address - Phone:617-323-6544
Practice Address - Fax:617-469-5627
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH235371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist