Provider Demographics
NPI:1083279822
Name:KIM, SUN MI
Entity Type:Individual
Prefix:
First Name:SUN
Middle Name:MI
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 1:2100 COLUMBUS PKWY
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-5402
Mailing Address - Country:US
Mailing Address - Phone:925-818-1674
Mailing Address - Fax:
Practice Address - Street 1:2100 COLUMBUS PKWY
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-5402
Practice Address - Country:US
Practice Address - Phone:707-747-3453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist