Provider Demographics
NPI:1003198458
Name:KIM, MARK Y (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N ALAMO ROAD
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TX
Mailing Address - Zip Code:78516
Mailing Address - Country:US
Mailing Address - Phone:956-782-4779
Mailing Address - Fax:
Practice Address - Street 1:510 N ALAMO RD
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TX
Practice Address - Zip Code:78516-2306
Practice Address - Country:US
Practice Address - Phone:956-782-4779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist