Provider Demographics
NPI:1629545710
Name:KOO, JIN
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:
Last Name:KOO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 S 320TH ST
Mailing Address - Street 2:STE G
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5344
Mailing Address - Country:US
Mailing Address - Phone:253-719-8554
Mailing Address - Fax:
Practice Address - Street 1:1014 S 320TH ST
Practice Address - Street 2:STE G
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5344
Practice Address - Country:US
Practice Address - Phone:253-719-8554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-27
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60877223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist