Provider Demographics
NPI:1477067635
Name:KIM, TAEJUNE
Entity Type:Individual
Prefix:
First Name:TAEJUNE
Middle Name:
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 1:25751 VAN LEUVEN ST APT 60
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2543
Mailing Address - Country:US
Mailing Address - Phone:951-532-4343
Mailing Address - Fax:
Practice Address - Street 1:14555 VALLEY CENTER DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4216
Practice Address - Country:US
Practice Address - Phone:760-524-9911
Practice Address - Fax:760-524-9908
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist