Provider Demographics
NPI:1609902238
Name:KIM, LEE SUNG (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:SUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:SUNG
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:17742 BEACH BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6818
Mailing Address - Country:US
Mailing Address - Phone:714-848-4447
Mailing Address - Fax:
Practice Address - Street 1:17742 BEACH BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6818
Practice Address - Country:US
Practice Address - Phone:714-848-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH32616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist