Provider Demographics
NPI:1790441715
Name:FUANGTHAISONG, JUTHAMAT
Entity Type:Individual
Prefix:
First Name:JUTHAMAT
Middle Name:
Last Name:FUANGTHAISONG
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 1:4098 EDGMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4098 EDGMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-2211
Practice Address - Country:US
Practice Address - Phone:610-876-8815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP455507183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist