Provider Demographics
NPI:1881001634
Name:KIM, ANGIE (PH60460468)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PH60460468
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 BURNETT AVE S
Mailing Address - Street 2:B104
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2107
Mailing Address - Country:US
Mailing Address - Phone:253-720-4425
Mailing Address - Fax:
Practice Address - Street 1:932 E FRONT ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4015
Practice Address - Country:US
Practice Address - Phone:360-457-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60460468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist