Provider Demographics
NPI:1598013674
Name:KIM, YOUNG
Entity Type:Individual
Prefix:
First Name:YOUNG
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 1:3609 200TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1112
Mailing Address - Country:US
Mailing Address - Phone:718-799-6392
Mailing Address - Fax:
Practice Address - Street 1:100 TECHNOLOGY CENTER DR
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-4710
Practice Address - Country:US
Practice Address - Phone:347-266-9957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057207183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist