Provider Demographics
NPI:1649223454
Name:KIM, JUNG S
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:S
Last Name:KIM
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 1:3511 W OLYMPIC BLVD
Mailing Address - Street 2:#102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3563
Mailing Address - Country:US
Mailing Address - Phone:323-731-0600
Mailing Address - Fax:323-731-9787
Practice Address - Street 1:3511 W OLYMPIC BLVD
Practice Address - Street 2:#102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-3563
Practice Address - Country:US
Practice Address - Phone:323-731-0600
Practice Address - Fax:323-731-9787
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5726360001Medicaid
CA5159080001Medicare ID - Type Unspecified