Provider Demographics
NPI:1932889565
Name:KING, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:KING
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 1:11975 EL CAMINO REAL STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2541
Mailing Address - Country:US
Mailing Address - Phone:310-903-7504
Mailing Address - Fax:
Practice Address - Street 1:11975 EL CAMINO REAL STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2541
Practice Address - Country:US
Practice Address - Phone:866-701-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89427183500000X
INT45817390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes183500000XPharmacy Service ProvidersPharmacist