Provider Demographics
NPI:1396849345
Name:KIMPHARMACY JS INC
Entity Type:Organization
Organization Name:KIMPHARMACY JS INC
Other - Org Name:KIM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAEHOON
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:714-534-4555
Mailing Address - Street 1:9828 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1639
Mailing Address - Country:US
Mailing Address - Phone:714-534-4555
Mailing Address - Fax:714-534-5127
Practice Address - Street 1:9828 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1639
Practice Address - Country:US
Practice Address - Phone:714-534-4555
Practice Address - Fax:714-534-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY553673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA323540Medicaid
2001145OtherPK
0571477OtherNCPDP PROVIDER IDENTIFICATION NUMBER