Healthcare Provider Details

I. General information

NPI: 1609488642
Provider Name (Legal Business Name): LEAKANA KHENG PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N CENTRAL AVE
GLENDALE CA
91203-2502
US

IV. Provider business mailing address

125 N CENTRAL AVE
GLENDALE CA
91203-2502
US

V. Phone/Fax

Practice location:
  • Phone: 818-637-2758
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number83041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: