Provider Demographics
NPI:1003697756
Name:MEDINA MORENO, KENIA YULISSA
Entity Type:Individual
Prefix:
First Name:KENIA
Middle Name:YULISSA
Last Name:MEDINA MORENO
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 1:2237 MCALLISTER LN
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-2673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-576-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist