Basic Information
| Provider Information | |||||||||
| NPI: | 1992181960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | KENRIC | ||||||||
| MiddleName: | KIN MING | ||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075213891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1165 MONTGOMERY DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075255300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2015 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 73310 | CA | N | Pharmacy Service Providers | Pharmacist | 183500000X | 051298742 | IL | N | Pharmacy Service Providers | Pharmacist | 1835X0200X | 73310 | CA | Y | Pharmacy Service Providers | Pharmacist | Oncology |
No ID Information.