=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619067774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH T. KOKUBUN PHARM D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25825 VERMONT AVE
-----------------------------------------------------
City | HARBOR CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90710-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-517-2276
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18331 FIELDBURY LN
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92648-1055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH28789
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------