Provider Demographics
NPI:1578047684
Name:KIM, JOHN JONG (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JONG
Last Name:KIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10095 WARD RD
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:MD
Mailing Address - Zip Code:20754-2731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10095 WARD RD
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-2731
Practice Address - Country:US
Practice Address - Phone:410-257-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11378339250Medicaid