Provider Demographics
NPI:1992461370
Name:NONTHANAM, TIPPAWAN
Entity type:Individual
Prefix:
First Name:TIPPAWAN
Middle Name:
Last Name:NONTHANAM
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 1:11221 NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2631
Mailing Address - Country:US
Mailing Address - Phone:240-725-8956
Mailing Address - Fax:
Practice Address - Street 1:9719 TRAVILLE GATEWAY DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-7408
Practice Address - Country:US
Practice Address - Phone:240-725-8956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28307183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist