Provider Demographics
NPI:1619245529
Name:KIM, KYUNGSUN JEONG (PHARM D)
Entity Type:Individual
Prefix:
First Name:KYUNGSUN
Middle Name:JEONG
Last Name:KIM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 S 960 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-3569
Mailing Address - Country:US
Mailing Address - Phone:801-288-0413
Mailing Address - Fax:801-288-2485
Practice Address - Street 1:5353 S 960 E
Practice Address - Street 2:#103
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-3569
Practice Address - Country:US
Practice Address - Phone:801-288-4013
Practice Address - Fax:801-288-2485
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT58905541701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT58905541701OtherUTAH DEPARTMENT OF COMMERCE FOR PHARMACY