Provider Demographics
NPI:1922328558
Name:KIM, MONA S
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:S
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 1:531 N GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-3307
Mailing Address - Country:US
Mailing Address - Phone:818-241-9770
Mailing Address - Fax:818-241-1965
Practice Address - Street 1:531 N GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-3307
Practice Address - Country:US
Practice Address - Phone:818-241-9770
Practice Address - Fax:818-241-1965
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-05
Last Update Date:2010-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46533C183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist