Provider Demographics
NPI:1790887511
Name:SAYAVONG, BOPHA H (RPH)
Entity Type:Individual
Prefix:
First Name:BOPHA
Middle Name:H
Last Name:SAYAVONG
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 1:600 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1050
Mailing Address - Country:US
Mailing Address - Phone:618-985-8822
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-998-5804
Practice Address - Fax:618-993-4188
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist