Provider Demographics
NPI:1568131738
Name:GOV, KENNETH TIMOTHY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:TIMOTHY
Last Name:GOV
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 S STATE COLLEGE BLVD APT 439
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-0180
Mailing Address - Country:US
Mailing Address - Phone:626-627-1434
Mailing Address - Fax:
Practice Address - Street 1:14555 VALLEY CENTER DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4219
Practice Address - Country:US
Practice Address - Phone:760-524-9904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist