Provider Demographics
NPI:1427739291
Name:PRACHYA, KEN
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:PRACHYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11647 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-7016
Mailing Address - Country:US
Mailing Address - Phone:562-991-3695
Mailing Address - Fax:
Practice Address - Street 1:11647 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-7016
Practice Address - Country:US
Practice Address - Phone:562-991-3695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist