Provider Demographics
NPI:1699233486
Name:RATTANA, SOUPHONE PONE (RPH)
Entity type:Individual
Prefix:
First Name:SOUPHONE
Middle Name:PONE
Last Name:RATTANA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 W COMMONWEALTH LN
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4954
Mailing Address - Country:US
Mailing Address - Phone:630-941-1688
Mailing Address - Fax:
Practice Address - Street 1:474 W COMMONWEALTH LN
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4954
Practice Address - Country:US
Practice Address - Phone:630-941-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist