Provider Demographics
NPI:1841968385
Name:KAEWTAVORN, ANDREW AKAPOB
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:AKAPOB
Last Name:KAEWTAVORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 N IVY ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-2722
Mailing Address - Country:US
Mailing Address - Phone:909-247-5534
Mailing Address - Fax:
Practice Address - Street 1:725 CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-3536
Practice Address - Country:US
Practice Address - Phone:760-871-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA82842OtherREGISTERED PHARMACIST