Provider Demographics
NPI:1356817951
Name:KIM, EDWARD JEFFREY
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JEFFREY
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4102
Mailing Address - Country:US
Mailing Address - Phone:213-480-3322
Mailing Address - Fax:213-401-0002
Practice Address - Street 1:461 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-4102
Practice Address - Country:US
Practice Address - Phone:213-480-3322
Practice Address - Fax:213-401-0002
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist