Provider Demographics
NPI:1376605477
Name:KIM, JIN HO (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:JIN
Middle Name:HO
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12582 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3507
Mailing Address - Country:US
Mailing Address - Phone:909-591-7420
Mailing Address - Fax:909-902-9480
Practice Address - Street 1:12582 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3507
Practice Address - Country:US
Practice Address - Phone:909-591-7420
Practice Address - Fax:909-902-9480
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0588953Medicare UPIN