Healthcare Provider Details

I. General information

NPI: 1548150626
Provider Name (Legal Business Name): KIMBERLY IVANSON PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 HAVEMEYER LN
REDONDO BEACH CA
90278-4717
US

IV. Provider business mailing address

1728 HAVEMEYER LN
REDONDO BEACH CA
90278-4717
US

V. Phone/Fax

Practice location:
  • Phone: 310-753-9047
  • Fax:
Mailing address:
  • Phone: 310-753-9047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number46392
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number46392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: