Provider Demographics
NPI:1730284126
Name:TOM, KEVIN STUART (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:STUART
Last Name:TOM
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 1:1355 FLORIN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-4200
Mailing Address - Country:US
Mailing Address - Phone:916-422-7384
Mailing Address - Fax:916-422-3876
Practice Address - Street 1:1355 FLORIN RD STE 1
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-4200
Practice Address - Country:US
Practice Address - Phone:916-422-7384
Practice Address - Fax:916-422-3876
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45399128OtherSTATE TAX ID NUMBER
CAPHA445700OtherMEDI-CAL ID NUMBER
CA42600OtherPHARMACIST LICENSE
CAPHY44570OtherPHARMACY STATE LICENSE
CAPHY44570OtherPHARMACY STATE LICENSE