Provider Demographics
NPI:1093128670
Name:KIM, SERA
Entity Type:Individual
Prefix:
First Name:SERA
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 1:305 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-1826
Mailing Address - Country:US
Mailing Address - Phone:201-849-5157
Mailing Address - Fax:201-849-5158
Practice Address - Street 1:305 BROAD AVE
Practice Address - Street 2:
Practice Address - City:LEONIA
Practice Address - State:NJ
Practice Address - Zip Code:07605-1826
Practice Address - Country:US
Practice Address - Phone:201-849-5157
Practice Address - Fax:201-849-5158
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03427800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist