Provider Demographics
NPI:1235700444
Name:TRAN, KEVIN K
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:TRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1828
Mailing Address - Country:US
Mailing Address - Phone:707-443-8039
Mailing Address - Fax:
Practice Address - Street 1:150 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-1828
Practice Address - Country:US
Practice Address - Phone:909-620-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84383333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy