Healthcare Provider Details

I. General information

NPI: 1194184366
Provider Name (Legal Business Name): GRACE KIM PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

IV. Provider business mailing address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

V. Phone/Fax

Practice location:
  • Phone: 707-566-5929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number55714
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: