Provider Demographics
NPI:1245832708
Name:KONGSOMBOONVECH, PISIWAT (PHARMD)
Entity type:Individual
Prefix:DR
First Name:PISIWAT
Middle Name:
Last Name:KONGSOMBOONVECH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3471 W CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-1218
Mailing Address - Country:US
Mailing Address - Phone:310-677-5937
Mailing Address - Fax:
Practice Address - Street 1:3471 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-1218
Practice Address - Country:US
Practice Address - Phone:310-677-5937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist