Provider Demographics
NPI:1053827659
Name:KIM, JI YOUNG
Entity Type:Individual
Prefix:
First Name:JI YOUNG
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 1:1555 MAIN ST APT 202
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-4070
Mailing Address - Country:US
Mailing Address - Phone:908-463-2011
Mailing Address - Fax:
Practice Address - Street 1:1555 MAIN ST APT 202
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-4070
Practice Address - Country:US
Practice Address - Phone:908-463-2011
Practice Address - Fax:908-463-2011
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03847600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist