Healthcare Provider Details

I. General information

NPI: 1720641426
Provider Name (Legal Business Name): KEVIN JAY LIEN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 MARTIN LUTHER KING JR BLVD
LYNWOOD CA
90262-3602
US

IV. Provider business mailing address

1207 W 168TH ST UNIT C
GARDENA CA
90247-5561
US

V. Phone/Fax

Practice location:
  • Phone: 310-637-2509
  • Fax:
Mailing address:
  • Phone: 310-819-0697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number79497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: