Provider Demographics
NPI:1285031427
Name:KIM, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:207 WESTPORT BAY DR
Mailing Address - Street 2:APT 304
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6380
Mailing Address - Country:US
Mailing Address - Phone:443-570-0960
Mailing Address - Fax:
Practice Address - Street 1:6301 YORK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-2636
Practice Address - Country:US
Practice Address - Phone:443-524-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21005183500000X
VA0202212706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist