Provider Demographics
NPI:1750856423
Name:KIM, EVELYN LANA
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:LANA
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 1:4500 WISCONSIN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4628
Mailing Address - Country:US
Mailing Address - Phone:202-244-1206
Mailing Address - Fax:
Practice Address - Street 1:4500 WISCONSIN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4628
Practice Address - Country:US
Practice Address - Phone:202-244-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210579183500000X
MD21001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist