Provider Demographics
NPI:1740442474
Name:SOUMPHOLPHAKDY, OUDALOM (PHARMD, PHC)
Entity type:Individual
Prefix:DR
First Name:OUDALOM
Middle Name:
Last Name:SOUMPHOLPHAKDY
Suffix:
Gender:M
Credentials:PHARMD, PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2432
Mailing Address - Country:US
Mailing Address - Phone:505-200-3440
Mailing Address - Fax:505-200-3436
Practice Address - Street 1:11001 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2432
Practice Address - Country:US
Practice Address - Phone:505-200-3440
Practice Address - Fax:505-200-3436
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006608183500000X, 183500000X
NMPC000001491835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist