Healthcare Provider Details

I. General information

NPI: 1427584044
Provider Name (Legal Business Name): KMTV INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 WASHINGTON BLVD. STE. C
MONTEBELLO CA
90640-6179
US

IV. Provider business mailing address

825 WASHINGTON BLVD. STE. C
MONTEBELLO CA
90640-6179
US

V. Phone/Fax

Practice location:
  • Phone: 323-278-0016
  • Fax: 323-278-0019
Mailing address:
  • Phone: 323-278-0016
  • Fax: 323-278-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number55542
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MINH DO
Title or Position: CEO/CFO/SEC./DIR.
Credential:
Phone: 408-821-7425