Provider Demographics
NPI:1477092880
Name:KIM, JEONG BEOM
Entity Type:Individual
Prefix:
First Name:JEONG BEOM
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 1:11800 NE 124TH AVE UNIT N181
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-1603
Mailing Address - Country:US
Mailing Address - Phone:773-459-5525
Mailing Address - Fax:
Practice Address - Street 1:2521 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2649
Practice Address - Country:US
Practice Address - Phone:360-693-2524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60658048183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist