Provider Demographics
NPI:1053502443
Name:IMAZUMI, KEITH HIROSHI (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:HIROSHI
Last Name:IMAZUMI
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 1:2504 ASCOT WAY
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1815
Mailing Address - Country:US
Mailing Address - Phone:510-414-0847
Mailing Address - Fax:
Practice Address - Street 1:2504 ASCOT WAY
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1815
Practice Address - Country:US
Practice Address - Phone:510-414-0847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist