Basic Information
| Provider Information | |||||||||
| NPI: | 1326528316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAM | ||||||||
| FirstName: | KEVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15176 EL SELINDA DR | ||||||||
| Address2: | |||||||||
| City: | HACIENDA HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917455153 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 HILLMONT AVE | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930031651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056526000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2018 | ||||||||
| LastUpdateDate: | 08/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 78743 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.