Provider Demographics
NPI:1003018524
Name:KIM, KWANG JA
Entity Type:Individual
Prefix:
First Name:KWANG JA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18102 PIONEER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-3997
Mailing Address - Country:US
Mailing Address - Phone:562-402-3636
Mailing Address - Fax:562-402-3676
Practice Address - Street 1:18102 PIONEER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-3997
Practice Address - Country:US
Practice Address - Phone:562-402-3636
Practice Address - Fax:562-402-3676
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 30573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist