Provider Demographics
NPI:1659656064
Name:LIM, JEANNE
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:LIM
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 1:1186 CALIMESA BLVD
Mailing Address - Street 2:
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320-1509
Mailing Address - Country:US
Mailing Address - Phone:909-795-1147
Mailing Address - Fax:909-795-4887
Practice Address - Street 1:1186 CALIMESA BLVD
Practice Address - Street 2:
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320-1509
Practice Address - Country:US
Practice Address - Phone:909-795-1147
Practice Address - Fax:909-795-4887
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH65810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist