Provider Demographics
NPI:1962766691
Name:SOURIVONG, STEVE
Entity type:Individual
Prefix:
First Name:STEVE
Middle Name:
Last Name:SOURIVONG
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 1:2207 W COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-1302
Mailing Address - Country:US
Mailing Address - Phone:626-282-6954
Mailing Address - Fax:626-282-0550
Practice Address - Street 1:2207 W COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-1302
Practice Address - Country:US
Practice Address - Phone:626-282-6954
Practice Address - Fax:626-282-0550
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2015-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist