Provider Demographics
NPI:1114552296
Name:KIM, JINAH
Entity Type:Individual
Prefix:
First Name:JINAH
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 1:545 COLUMBIA LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2450
Mailing Address - Country:US
Mailing Address - Phone:385-477-4942
Mailing Address - Fax:385-477-4945
Practice Address - Street 1:545 COLUMBIA LN
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2450
Practice Address - Country:US
Practice Address - Phone:385-477-4942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10696568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3008051Medicaid