Provider Demographics
NPI:1790916724
Name:KIM, JAY A (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:A
Last Name:KIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2604 DEMPSTER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8412
Mailing Address - Country:US
Mailing Address - Phone:847-296-1200
Mailing Address - Fax:847-296-7913
Practice Address - Street 1:2604 DEMPSTER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8412
Practice Address - Country:US
Practice Address - Phone:847-296-1200
Practice Address - Fax:847-296-7913
Is Sole Proprietor?:No
Enumeration Date:2009-08-08
Last Update Date:2009-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL051034220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist