Provider Demographics
NPI:1851159057
Name:KIM, YEONSOO
Entity Type:Individual
Prefix:
First Name:YEONSOO
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 1:70 RESERVOIR AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-2501
Mailing Address - Country:US
Mailing Address - Phone:774-641-3672
Mailing Address - Fax:
Practice Address - Street 1:73 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-3059
Practice Address - Country:US
Practice Address - Phone:201-796-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04088100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist