Provider Demographics
NPI:1679800155
Name:KIM, CHONG KI (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHONG KI
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5147 BURNSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-3711
Mailing Address - Country:US
Mailing Address - Phone:315-882-2064
Mailing Address - Fax:
Practice Address - Street 1:5399 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2265
Practice Address - Country:US
Practice Address - Phone:315-487-6714
Practice Address - Fax:315-487-0988
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY42867183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist