Provider Demographics
NPI:1063628527
Name:KIM, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
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 1:2889 PLAZA DEL AMO
Mailing Address - Street 2:UNIT 525
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-7377
Mailing Address - Country:US
Mailing Address - Phone:310-533-1435
Mailing Address - Fax:
Practice Address - Street 1:3400 LOMITA BLVD
Practice Address - Street 2:STE 102
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4909
Practice Address - Country:US
Practice Address - Phone:310-530-3010
Practice Address - Fax:310-530-7618
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54014183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA44389Medicaid
CA4644760001Medicare ID - Type Unspecified