Provider Demographics
NPI:1225387848
Name:KIM, STEPHEN S (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SE LOOP 820
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-5863
Mailing Address - Country:US
Mailing Address - Phone:817-730-0000
Mailing Address - Fax:
Practice Address - Street 1:2201 SE LOOP 820
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-5863
Practice Address - Country:US
Practice Address - Phone:817-730-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist