Provider Demographics
NPI:1326636127
Name:HOANG, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HOANG
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 1:436 S BELLA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2706
Mailing Address - Country:US
Mailing Address - Phone:714-470-3829
Mailing Address - Fax:
Practice Address - Street 1:200 WESTMINSTER MALL
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4984
Practice Address - Country:US
Practice Address - Phone:714-657-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist