Provider Demographics
NPI:1578642245
Name:KIM SON PHARMACY
Entity Type:Organization
Organization Name:KIM SON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:KIM CHI
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-571-5967
Mailing Address - Street 1:625 E VALLEY BLVD
Mailing Address - Street 2:STE J
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3591
Mailing Address - Country:US
Mailing Address - Phone:626-571-5967
Mailing Address - Fax:626-571-5968
Practice Address - Street 1:625 E VALLEY BLVD
Practice Address - Street 2:SUITE J
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3591
Practice Address - Country:US
Practice Address - Phone:626-571-5967
Practice Address - Fax:626-571-5968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA345770Medicaid
0578522OtherOTHER ID NUMBER-COMMERCIAL NUMBER