Healthcare Provider Details

I. General information

NPI: 1508429150
Provider Name (Legal Business Name): KELLY TRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 ATLANTIC AVE
LONG BEACH CA
90807-4515
US

IV. Provider business mailing address

3575 ATLANTIC AVE
LONG BEACH CA
90807-4515
US

V. Phone/Fax

Practice location:
  • Phone: 562-997-8743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number58205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: