Provider Demographics
NPI:1659821320
Name:KIM, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
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 1:8051 BENELLI CT
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3596
Mailing Address - Country:US
Mailing Address - Phone:714-260-3589
Mailing Address - Fax:
Practice Address - Street 1:8051 BENELLI CT
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-3596
Practice Address - Country:US
Practice Address - Phone:714-260-3589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist