Provider Demographics
NPI:1235473174
Name:KIM, JAE YOUNG (PHARM D)
Entity Type:Individual
Prefix:
First Name:JAE YOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16830 SAN FERNANDO MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4247
Mailing Address - Country:US
Mailing Address - Phone:818-831-5059
Mailing Address - Fax:818-832-6541
Practice Address - Street 1:16830 SAN FERNANDO MISSION BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4247
Practice Address - Country:US
Practice Address - Phone:818-831-5059
Practice Address - Fax:818-832-6541
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19825183500000X
NC22534183500000X
CA71953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist