Provider Demographics
NPI:1306409123
Name:KIM, YEUN SOO (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:YEUN SOO
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 W HENDERSON AVE APT 160
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1598
Mailing Address - Country:US
Mailing Address - Phone:419-673-5127
Mailing Address - Fax:
Practice Address - Street 1:1155 W HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1452
Practice Address - Country:US
Practice Address - Phone:559-784-3317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist