Provider Demographics
NPI:1013402098
Name:BAE, KAREN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 S VINEYARD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7927
Mailing Address - Country:US
Mailing Address - Phone:909-724-7661
Mailing Address - Fax:
Practice Address - Street 1:17284 SLOVER AVE STE 204
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7584
Practice Address - Country:US
Practice Address - Phone:909-609-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77569183500000X
CA775681835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist