Provider Demographics
NPI:1073888483
Name:KIM, JIN TAE (RPH)
Entity Type:Individual
Prefix:
First Name:JIN TAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 LAKEWAY DR
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-6219
Mailing Address - Country:US
Mailing Address - Phone:360-738-4243
Mailing Address - Fax:360-738-8033
Practice Address - Street 1:800 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-6219
Practice Address - Country:US
Practice Address - Phone:360-738-4243
Practice Address - Fax:360-738-8033
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00042870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist