Provider Demographics
NPI:1205212909
Name:KIM, HARRISON J
Entity Type:Individual
Prefix:
First Name:HARRISON
Middle Name:J
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 1:10301 NEW GUINEA RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3268
Mailing Address - Country:US
Mailing Address - Phone:703-764-5112
Mailing Address - Fax:703-828-1728
Practice Address - Street 1:10301 NEW GUINEA RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-3268
Practice Address - Country:US
Practice Address - Phone:703-764-5112
Practice Address - Fax:703-828-1728
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230026712183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician