Provider Demographics
NPI:1720641426
Name:LIEN, KEVIN JAY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAY
Last Name:LIEN
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 1:1207 W 168TH ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5561
Mailing Address - Country:US
Mailing Address - Phone:310-819-0697
Mailing Address - Fax:
Practice Address - Street 1:3800 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3602
Practice Address - Country:US
Practice Address - Phone:310-637-2509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist