Provider Demographics
NPI:1770991200
Name:PHAM, KENNETH (PHARMD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PHAM
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 1:4080 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-5900
Mailing Address - Country:US
Mailing Address - Phone:916-380-3262
Mailing Address - Fax:
Practice Address - Street 1:4080 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-5900
Practice Address - Country:US
Practice Address - Phone:916-380-3262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH64700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist