Provider Demographics
NPI:1306458955
Name:PHOUANGMANIVANH, JULY
Entity type:Individual
Prefix:
First Name:JULY
Middle Name:
Last Name:PHOUANGMANIVANH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 CASTELLO CIR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-7725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36832-5870
Practice Address - Country:US
Practice Address - Phone:334-821-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21234183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist