Provider Demographics
NPI:1528606100
Name:PHAM, KENT
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:PHAM
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 1:220 E COMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-2413
Mailing Address - Country:US
Mailing Address - Phone:310-604-1747
Mailing Address - Fax:310-604-0631
Practice Address - Street 1:220 E COMPTON BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-2413
Practice Address - Country:US
Practice Address - Phone:310-604-1747
Practice Address - Fax:310-604-0631
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist