Provider Demographics
NPI:1912208232
Name:CHANTHAVONG, DESARONE (RPH)
Entity Type:Individual
Prefix:
First Name:DESARONE
Middle Name:
Last Name:CHANTHAVONG
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 1:11696 NE 76TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3941
Mailing Address - Country:US
Mailing Address - Phone:360-944-2665
Mailing Address - Fax:360-944-2669
Practice Address - Street 1:11696 NE 76TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3941
Practice Address - Country:US
Practice Address - Phone:360-944-2665
Practice Address - Fax:360-944-2669
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00017390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist