Provider Demographics
NPI:1821411521
Name:KIM, MAN
Entity Type:Individual
Prefix:
First Name:MAN
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 1:20137 PIONEER BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-1051
Mailing Address - Country:US
Mailing Address - Phone:562-924-1210
Mailing Address - Fax:562-924-3430
Practice Address - Street 1:20137 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90715-1051
Practice Address - Country:US
Practice Address - Phone:562-924-1210
Practice Address - Fax:562-924-3430
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist