Provider Demographics
NPI:1811368376
Name:KIM, SOO
Entity Type:Individual
Prefix:MRS
First Name:SOO
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 1:757 GALAXY HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:LA CANADA FLINTRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1832
Mailing Address - Country:US
Mailing Address - Phone:213-248-1542
Mailing Address - Fax:
Practice Address - Street 1:757 GALAXY HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:LA CANADA FLINTRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91011-1832
Practice Address - Country:US
Practice Address - Phone:213-248-1542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist