Provider Demographics
NPI:1265052377
Name:VONGNALITH, WARINSIRI (RPH)
Entity type:Individual
Prefix:
First Name:WARINSIRI
Middle Name:
Last Name:VONGNALITH
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 1:8971 SHASTA LILY DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-3870
Mailing Address - Country:US
Mailing Address - Phone:916-897-6493
Mailing Address - Fax:
Practice Address - Street 1:10451 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-1987
Practice Address - Country:US
Practice Address - Phone:916-780-2898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-18
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81722183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist