Provider Demographics
NPI:1922397603
Name:KIM, MOONJOO S
Entity Type:Individual
Prefix:
First Name:MOONJOO
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 1:1583 HIGHWAY 99
Mailing Address - Street 2:RITE AID PHARMACY
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-3107
Mailing Address - Country:US
Mailing Address - Phone:530-846-3334
Mailing Address - Fax:530-846-0729
Practice Address - Street 1:1583 HIGHWAY 99
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-3107
Practice Address - Country:US
Practice Address - Phone:530-846-3334
Practice Address - Fax:530-846-0729
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57389OtherCALIFORNIA BOARD OF PHARMACY