Provider Demographics
NPI:1629378609
Name:WAHLSTROM, KENNETH (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:WAHLSTROM
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 1:32401 CAMINO CAPISTRANO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4531
Mailing Address - Country:US
Mailing Address - Phone:949-661-3492
Mailing Address - Fax:949-661-6205
Practice Address - Street 1:32401 CAMINO CAPISTRANO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-4517
Practice Address - Country:US
Practice Address - Phone:949-661-3492
Practice Address - Fax:949-661-6205
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH51053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist