Provider Demographics
NPI:1376855379
Name:KIM, YONG JIN
Entity Type:Individual
Prefix:
First Name:YONG
Middle Name:JIN
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 1:9 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:894 6TH AVE
Practice Address - Street 2:MEZZANINE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3508
Practice Address - Country:US
Practice Address - Phone:212-695-4232
Practice Address - Fax:212-695-8658
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033012183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist