Provider Demographics
NPI:1518477801
Name:KIM, BUMSOO
Entity Type:Individual
Prefix:
First Name:BUMSOO
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 1:505 GARFIELD PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:218 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3436
Practice Address - Country:US
Practice Address - Phone:707-829-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77269OtherBOARD OF PHARMACY