Provider Demographics
NPI:1396029765
Name:KIM, TIFFANY BORA
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:BORA
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 1:2472 RAYWOOD VW
Mailing Address - Street 2:624
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7759
Mailing Address - Country:US
Mailing Address - Phone:720-277-7433
Mailing Address - Fax:
Practice Address - Street 1:280 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-1712
Practice Address - Country:US
Practice Address - Phone:720-277-7433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist