Provider Demographics
NPI:1861591919
Name:TRAN, CUC KIM (OWNER)
Entity type:Individual
Prefix:
First Name:CUC
Middle Name:KIM
Last Name:TRAN
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14150 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-4657
Mailing Address - Country:US
Mailing Address - Phone:714-590-9401
Mailing Address - Fax:714-590-9484
Practice Address - Street 1:14150 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-4657
Practice Address - Country:US
Practice Address - Phone:714-590-9401
Practice Address - Fax:714-590-9484
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 45497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA454970Medicaid
CAPHA454970Medicaid