Provider Demographics
NPI:1902402423
Name:KIM, JI SOO
Entity Type:Individual
Prefix:
First Name:JI SOO
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JISOO
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:120 EDDIE DOWLING HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02896-8214
Mailing Address - Country:US
Mailing Address - Phone:401-762-3172
Mailing Address - Fax:
Practice Address - Street 1:120 EDDIE DOWLING HWY
Practice Address - Street 2:
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-8214
Practice Address - Country:US
Practice Address - Phone:401-762-3172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH05822183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist