Provider Demographics
NPI:1629609078
Name:LI, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LI
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 1:12786 SW FALCON RISE DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4744
Mailing Address - Country:US
Mailing Address - Phone:503-715-2886
Mailing Address - Fax:
Practice Address - Street 1:3099 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2432
Practice Address - Country:US
Practice Address - Phone:360-879-5212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61003988183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist