Provider Demographics
NPI:1043826183
Name:LA, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:LA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11043 KLINGERMAN ST
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-2822
Mailing Address - Country:US
Mailing Address - Phone:626-377-1951
Mailing Address - Fax:
Practice Address - Street 1:612 W DUARTE RD STE 102
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9221
Practice Address - Country:US
Practice Address - Phone:626-377-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist