Provider Demographics
NPI:1780908053
Name:WILLIAMS, KISHA
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 E ELSMERE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2637
Mailing Address - Country:US
Mailing Address - Phone:310-259-8030
Mailing Address - Fax:
Practice Address - Street 1:645 E CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2720
Practice Address - Country:US
Practice Address - Phone:310-830-8927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96609183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician