Provider Demographics
NPI:1013459254
Name:MAK, KEN (PHARMD)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:MAK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SMITH RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1900
Mailing Address - Country:US
Mailing Address - Phone:415-492-6369
Mailing Address - Fax:
Practice Address - Street 1:100 SMITH RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1900
Practice Address - Country:US
Practice Address - Phone:415-492-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist