Provider Demographics
NPI:1922601798
Name:KIM, SHINSOOK
Entity Type:Individual
Prefix:
First Name:SHINSOOK
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 1:7500 CENTREVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20111-1743
Mailing Address - Country:US
Mailing Address - Phone:703-369-1920
Mailing Address - Fax:703-369-3620
Practice Address - Street 1:7500 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20111-1743
Practice Address - Country:US
Practice Address - Phone:703-369-1920
Practice Address - Fax:703-369-3620
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202204890OtherVIRGINIA PHARMACIST