Provider Demographics
NPI:1104244235
Name:QUACH, KIMMY
Entity type:Individual
Prefix:
First Name:KIMMY
Middle Name:
Last Name:QUACH
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 1:2183 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1520
Mailing Address - Country:US
Mailing Address - Phone:786-218-3461
Mailing Address - Fax:
Practice Address - Street 1:2183 42ND AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-1520
Practice Address - Country:US
Practice Address - Phone:786-218-3461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-05
Last Update Date:2014-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist