Provider Demographics
NPI:1225247687
Name:KIM, MARIO I (BS)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:I
Last Name:KIM
Suffix:
Gender:M
Credentials:BS
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Mailing Address - Street 1:6152 LITTLE NECK PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2419
Mailing Address - Country:US
Mailing Address - Phone:718-631-8850
Mailing Address - Fax:718-631-8850
Practice Address - Street 1:88 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3710
Practice Address - Country:US
Practice Address - Phone:516-377-8500
Practice Address - Fax:516-377-8501
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY046578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist