Provider Demographics
NPI:1073850780
Name:KIM, MYOUNG
Entity Type:Individual
Prefix:
First Name:MYOUNG
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 1:5805 STATE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8220
Mailing Address - Country:US
Mailing Address - Phone:770-813-7456
Mailing Address - Fax:770-813-7459
Practice Address - Street 1:5805 STATE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8220
Practice Address - Country:US
Practice Address - Phone:770-813-7456
Practice Address - Fax:770-813-7459
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist