Provider Demographics
NPI:1205284965
Name:RATSAPHANGTHONG, ILKA
Entity type:Individual
Prefix:
First Name:ILKA
Middle Name:
Last Name:RATSAPHANGTHONG
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 1:1441 N BECKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1201
Mailing Address - Country:US
Mailing Address - Phone:214-947-2481
Mailing Address - Fax:214-947-2402
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-947-2481
Practice Address - Fax:214-947-2402
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist