Provider Demographics
NPI:1932517257
Name:KONGKIM, JA YOUNG
Entity Type:Individual
Prefix:
First Name:JA YOUNG
Middle Name:
Last Name:KONGKIM
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 1:4195 PLEASANT HILL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6343
Mailing Address - Country:US
Mailing Address - Phone:727-667-4692
Mailing Address - Fax:
Practice Address - Street 1:4195 PLEASANT HILL RD
Practice Address - Street 2:SUITE D
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6343
Practice Address - Country:US
Practice Address - Phone:727-667-4692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARHP24694183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist