Provider Demographics
NPI:1063023604
Name:KIM, EUNAE
Entity Type:Individual
Prefix:
First Name:EUNAE
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 1:4060 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-3424
Mailing Address - Country:US
Mailing Address - Phone:703-236-0432
Mailing Address - Fax:703-940-1626
Practice Address - Street 1:4060 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-3424
Practice Address - Country:US
Practice Address - Phone:703-236-0432
Practice Address - Fax:703-940-1626
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0005450183500000X
VA0202218162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist