Provider Demographics
NPI:1093214322
Name:KIM, JI YOUNG
Entity Type:Individual
Prefix:
First Name:JI
Middle Name:YOUNG
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 1:33 WINDSOR CT
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-8109
Mailing Address - Country:US
Mailing Address - Phone:253-224-4644
Mailing Address - Fax:
Practice Address - Street 1:3411 E KOLONELS WAY
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362
Practice Address - Country:US
Practice Address - Phone:360-452-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60675028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist