Provider Demographics
NPI:1164993671
Name:KIM, KWAN YUNG
Entity Type:Individual
Prefix:
First Name:KWAN YUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 RIVER DR APT 36
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-3243
Mailing Address - Country:US
Mailing Address - Phone:609-865-3090
Mailing Address - Fax:
Practice Address - Street 1:919 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8529
Practice Address - Country:US
Practice Address - Phone:609-865-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03977400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist