Provider Demographics
NPI:1558884452
Name:KIM, HYUN KYUNG
Entity Type:Individual
Prefix:
First Name:HYUN
Middle Name:KYUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028-1771
Mailing Address - Country:US
Mailing Address - Phone:478-971-1288
Mailing Address - Fax:
Practice Address - Street 1:1331 GREEN ST
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-2749
Practice Address - Country:US
Practice Address - Phone:478-923-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist