Provider Demographics
NPI:1053840173
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 1:1940 W CHANDLER BLVD
Mailing Address - Street 2:STE 3
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6176
Mailing Address - Country:US
Mailing Address - Phone:480-835-0970
Mailing Address - Fax:
Practice Address - Street 1:1940 W CHANDLER BLVD
Practice Address - Street 2:STE 3
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6176
Practice Address - Country:US
Practice Address - Phone:480-835-0970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH76630183500000X
AZS022428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist