Provider Demographics
NPI:1235654195
Name:KIM, JUDITH
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7775 CHATFIELD LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-7916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2633 BRANDERMILL BLVD
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1645
Practice Address - Country:US
Practice Address - Phone:410-451-9448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist