Provider Demographics
NPI:1306994553
Name:SAN, KY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KY
Middle Name:
Last Name:SAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 DOLBEER ST
Mailing Address - Street 2:PHARMACY
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4736
Mailing Address - Country:US
Mailing Address - Phone:707-445-8121
Mailing Address - Fax:
Practice Address - Street 1:5329 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3237
Practice Address - Country:US
Practice Address - Phone:503-988-8264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW598753OtherPHARMACIST