Provider Demographics
NPI:1336595479
Name:PARDUNGKIATTISAK, EDISORN (PHARMD)
Entity Type:Individual
Prefix:
First Name:EDISORN
Middle Name:
Last Name:PARDUNGKIATTISAK
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 1:2940 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4004
Mailing Address - Country:US
Mailing Address - Phone:773-348-4155
Mailing Address - Fax:
Practice Address - Street 1:2940 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4004
Practice Address - Country:US
Practice Address - Phone:773-348-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-08
Last Update Date:2016-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist