Provider Demographics
NPI:1548583982
Name:KIM, JENNIFER (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 E 174TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-5202
Mailing Address - Country:US
Mailing Address - Phone:718-378-1200
Mailing Address - Fax:718-378-1300
Practice Address - Street 1:932 E 174TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-5202
Practice Address - Country:US
Practice Address - Phone:718-378-1200
Practice Address - Fax:718-378-1300
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047765-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist