Basic Information
| Provider Information | |||||||||
| NPI: | 1629390117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SOO | ||||||||
| MiddleName: | |||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14246 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113546042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188880808 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14246 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113546042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188880808 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2010 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 045404 | NY | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.