Provider Demographics
NPI:1821365776
Name:KIM, PETER
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3012
Mailing Address - Country:US
Mailing Address - Phone:847-215-8346
Mailing Address - Fax:847-215-8924
Practice Address - Street 1:10 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3012
Practice Address - Country:US
Practice Address - Phone:847-215-8346
Practice Address - Fax:847-215-8924
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist