Basic Information
Provider Information
NPI: 1790887511
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SAYAVONG
FirstName: BOPHA
MiddleName: H
NamePrefix:  
NameSuffix:  
Credential: RPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 600 ARBOR DR
Address2:  
City: CARTERVILLE
State: IL
PostalCode: 629181050
CountryCode: US
TelephoneNumber: 6189858822
FaxNumber:  
Practice Location
Address1: 2401 W MAIN ST
Address2:  
City: MARION
State: IL
PostalCode: 629591188
CountryCode: US
TelephoneNumber: 6189985804
FaxNumber: 6189934188
Other Information
ProviderEnumerationDate: 09/02/2006
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X ILY Pharmacy Service ProvidersPharmacist 

No ID Information.


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