Provider Demographics
NPI:1629324181
Name:CORUM, KENNETH LESLIE JR
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LESLIE
Last Name:CORUM
Suffix:JR
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 1:36010 HIDDEN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7622
Mailing Address - Country:US
Mailing Address - Phone:951-678-1755
Mailing Address - Fax:951-678-7677
Practice Address - Street 1:36010 HIDDEN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7622
Practice Address - Country:US
Practice Address - Phone:951-678-1755
Practice Address - Fax:951-678-7677
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist