Provider Demographics
NPI:1790234649
Name:JUAREZ, CHANTHAKHONE
Entity Type:Individual
Prefix:
First Name:CHANTHAKHONE
Middle Name:
Last Name:JUAREZ
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 1:575 DACULA RD
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2125
Mailing Address - Country:US
Mailing Address - Phone:770-962-2077
Mailing Address - Fax:770-962-2171
Practice Address - Street 1:575 DACULA RD
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-2125
Practice Address - Country:US
Practice Address - Phone:305-254-0323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42653183500000X
GARPH032388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist