Provider Demographics
NPI:1851984975
Name:KIM, JI MYUNG
Entity Type:Individual
Prefix:
First Name:JI MYUNG
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 1:230 A 3RD STREET
Mailing Address - Street 2:BASEMENT
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650
Mailing Address - Country:US
Mailing Address - Phone:857-409-1374
Mailing Address - Fax:
Practice Address - Street 1:450 BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1631
Practice Address - Country:US
Practice Address - Phone:201-947-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy