Provider Demographics
NPI:1891022380
Name:CHAROENPHOL, PRATANA
Entity Type:Individual
Prefix:
First Name:PRATANA
Middle Name:
Last Name:CHAROENPHOL
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 1:80 ACOMA BLVD N
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6932
Mailing Address - Country:US
Mailing Address - Phone:928-680-4449
Mailing Address - Fax:928-680-6122
Practice Address - Street 1:80 ACOMA BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6932
Practice Address - Country:US
Practice Address - Phone:928-680-4449
Practice Address - Fax:928-680-6122
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist