Provider Demographics
NPI:1659417343
Name:DEANNA T ON
Entity Type:Organization
Organization Name:DEANNA T ON
Other - Org Name:KIM LEADER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHRM D
Authorized Official - Prefix:
Authorized Official - First Name:TOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-392-3488
Mailing Address - Street 1:PO BOX 245036
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95824-5036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6665 STOCKTON BLVD STE 6
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-1634
Practice Address - Country:US
Practice Address - Phone:916-392-3488
Practice Address - Fax:916-392-3489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY456483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0563913OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5545660001Medicare NSC