Provider Demographics
NPI:1689399255
Name:QUAN, KENNETH RAYMOND (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAYMOND
Last Name:QUAN
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14781 POMERADO RD # 122
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2802
Mailing Address - Country:US
Mailing Address - Phone:858-255-9894
Mailing Address - Fax:
Practice Address - Street 1:3081B CLAIREMONT DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6802
Practice Address - Country:US
Practice Address - Phone:858-255-9894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86919OtherCA RPH LICENSE