Basic Information
| Provider Information | |||||||||
| NPI: | 1003898917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LO | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | KIMMAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2307 NE 4TH ST | ||||||||
| Address2: | H301 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980564083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256871263 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12844 MILITARY RD S | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981683045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062484625 | ||||||||
| FaxNumber: | 2062484627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH00043322 | WA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.