Healthcare Provider Details

I. General information

NPI: 1144510199
Provider Name (Legal Business Name): KISOO OH PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S STATE ST
UKIAH CA
95482-4913
US

IV. Provider business mailing address

680 S STATE ST
UKIAH CA
95482-4913
US

V. Phone/Fax

Practice location:
  • Phone: 707-462-6850
  • Fax: 707-462-0348
Mailing address:
  • Phone: 707-462-6850
  • Fax: 707-462-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: