Provider Demographics
NPI:1851760995
Name:KIM, JOHANNA MINJI
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:MINJI
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 1:2731 BRIERHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2731 BRIERHAVEN DR
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1403
Practice Address - Country:US
Practice Address - Phone:818-279-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist