Provider Demographics
NPI:1740413426
Name:VONGVICHITH, KEO KEVIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEO
Middle Name:KEVIN
Last Name:VONGVICHITH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:KEOMANY
Other - Middle Name:
Other - Last Name:VONGVICHITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605 MARTHA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-2926
Mailing Address - Country:US
Mailing Address - Phone:505-453-6121
Mailing Address - Fax:505-217-2557
Practice Address - Street 1:3632 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2851
Practice Address - Country:US
Practice Address - Phone:505-217-2551
Practice Address - Fax:505-217-2557
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist