Provider Demographics
NPI:1326348749
Name:KIM, ELISA O (RPH)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:O
Last Name:KIM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21401 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6074
Mailing Address - Country:US
Mailing Address - Phone:206-824-4784
Mailing Address - Fax:206-878-3208
Practice Address - Street 1:21401 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6074
Practice Address - Country:US
Practice Address - Phone:206-824-4784
Practice Address - Fax:206-878-3208
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00064091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist