Provider Demographics
NPI:1073906376
Name:LAM, KELLY TUYET
Entity Type:Individual
Prefix:
First Name:KELLY TUYET
Middle Name:
Last Name:LAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY TUYET
Other - Middle Name:
Other - Last Name:LAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOCTOR OF PHARMACY
Mailing Address - Street 1:660 W MARCH LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6200
Mailing Address - Country:US
Mailing Address - Phone:209-478-0891
Mailing Address - Fax:
Practice Address - Street 1:660 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6200
Practice Address - Country:US
Practice Address - Phone:209-478-0891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist