Healthcare Provider Details

I. General information

NPI: 1104859800
Provider Name (Legal Business Name): KKN PHARMACY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/04/2024
Certification Date: 08/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27881 LA PAZ RD STE E
LAGUNA NIGUEL CA
92677-3933
US

IV. Provider business mailing address

27881 LA PAZ RD STE E
LAGUNA NIGUEL CA
92677-3933
US

V. Phone/Fax

Practice location:
  • Phone: 949-643-0740
  • Fax: 949-643-2287
Mailing address:
  • Phone: 949-643-0740
  • Fax: 949-643-2287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number51753
License Number StateCA

VIII. Authorized Official

Name: NIHAR MANDAVIA
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 949-643-0740