MEDICARE: DR. KY SAN PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	53066	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W598753	OTHER	CA	PHARMACIST

General Provider Information

NPI Number	:	1306994553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KY SAN PHARM.D.

Provider Business Mailing Address
First Line	:	2700 DOLBEER ST
Second Line	:	PHARMACY
City	:	EUREKA
State	:	CA
Zip	:	95501-4736
Country	:	US
Telephone Number	:	707-445-8121
Fax Number	:

Provider Business Practice Location Address
First Line	:	5329 NE MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-3237
Country	:	US
Telephone Number	:	503-988-8264
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2007
Last Update Date	:	06/13/2023

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