Provider Demographics
NPI:1790157030
Name:VAN, KIM THI NGOC (RPH)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:THI NGOC
Last Name:VAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9475 FERMI AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3254
Mailing Address - Country:US
Mailing Address - Phone:716-698-1586
Mailing Address - Fax:
Practice Address - Street 1:1101 S MISSION RD
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3224
Practice Address - Country:US
Practice Address - Phone:760-723-5721
Practice Address - Fax:760-723-1336
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist