Provider Demographics
NPI:1508520370
Name:KIM, EUISUNG
Entity Type:Individual
Prefix:
First Name:EUISUNG
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 1:3550 JAMES SANDERS BLVD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9159
Mailing Address - Country:US
Mailing Address - Phone:270-444-6992
Mailing Address - Fax:
Practice Address - Street 1:3550 JAMES SANDERS BLVD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9159
Practice Address - Country:US
Practice Address - Phone:270-444-6992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist