Provider Demographics
NPI:1013662865
Name:KAN, WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:KAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81893 DR CARREON BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5592
Mailing Address - Country:US
Mailing Address - Phone:760-347-0659
Mailing Address - Fax:760-347-5972
Practice Address - Street 1:81893 DR CARREON BLVD STE 7
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5592
Practice Address - Country:US
Practice Address - Phone:760-347-0659
Practice Address - Fax:760-347-5972
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21267Medicaid