Provider Demographics
NPI:1356682710
Name:KIM, YOUNG O
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:O
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 1:3013 W STOLLEY PARK RD APT 83
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-7290
Mailing Address - Country:US
Mailing Address - Phone:312-505-6449
Mailing Address - Fax:
Practice Address - Street 1:1515 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-5715
Practice Address - Country:US
Practice Address - Phone:308-384-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist