Provider Demographics
NPI:1679000640
Name:KIM, MIN
Entity Type:Individual
Prefix:
First Name:MIN
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 1:1774 RED ROBIN PL
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-6567
Mailing Address - Country:US
Mailing Address - Phone:805-233-0208
Mailing Address - Fax:
Practice Address - Street 1:5800 SANTA ROSA RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-7056
Practice Address - Country:US
Practice Address - Phone:805-484-8208
Practice Address - Fax:805-389-0713
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-21
Last Update Date:2017-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48554183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist