Provider Demographics
NPI:1821363011
Name:KIM, DIANE DEOKSU (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:DEOKSU
Last Name:KIM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12582 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3507
Mailing Address - Country:US
Mailing Address - Phone:909-591-7429
Mailing Address - Fax:909-902-9480
Practice Address - Street 1:12582 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3507
Practice Address - Country:US
Practice Address - Phone:909-591-7429
Practice Address - Fax:909-902-9480
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist