Provider Demographics
NPI:1326691106
Name:YANG, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:YANG
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 1:5865 PROMENADE SHOPS BLVD
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-5600
Mailing Address - Country:US
Mailing Address - Phone:317-776-1175
Mailing Address - Fax:
Practice Address - Street 1:5865 PROMENADE SHOPS BLVD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-5600
Practice Address - Country:US
Practice Address - Phone:317-776-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-20
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019414A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0420196600OtherCAREMARK
0420196600OtherCIGNA
IN0420196600Medicaid
IN0420196600OtherEXPRESS SCIPT