Provider Demographics
NPI:1932272192
Name:BAE, KIOK
Entity Type:Individual
Prefix:MRS
First Name:KIOK
Middle Name:
Last Name:BAE
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 1:3400 W. LOMITA BLVD.
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-1305
Mailing Address - Country:US
Mailing Address - Phone:310-530-3010
Mailing Address - Fax:310-530-7618
Practice Address - Street 1:2212 BLUERIDGE CT
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1305
Practice Address - Country:US
Practice Address - Phone:714-870-5569
Practice Address - Fax:714-680-3675
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45366OtherPHARMACIST