Provider Demographics
NPI:1831645357
Name:KIM, JINTAE
Entity Type:Individual
Prefix:
First Name:JINTAE
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 1:2655 SANTA ANA ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2025
Mailing Address - Country:US
Mailing Address - Phone:323-582-5601
Mailing Address - Fax:323-582-6051
Practice Address - Street 1:2655 SANTA ANA ST
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2025
Practice Address - Country:US
Practice Address - Phone:323-582-5601
Practice Address - Fax:323-582-6051
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist