Provider Demographics
NPI:1821654377
Name:THONGVATHSA, SOUTSADA SANDY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SOUTSADA
Middle Name:SANDY
Last Name:THONGVATHSA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 ESTATE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3438
Mailing Address - Country:US
Mailing Address - Phone:763-742-9431
Mailing Address - Fax:
Practice Address - Street 1:12011 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3620
Practice Address - Country:US
Practice Address - Phone:952-943-4828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18851-40183500000X
MN123530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist