Provider Demographics
NPI:1952828154
Name:LIM, KHLOTH (MHA, PHARMD)
Entity Type:Individual
Prefix:
First Name:KHLOTH
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:MHA, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 SW HARRISON ST APT 20
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-2536
Mailing Address - Country:US
Mailing Address - Phone:503-740-4840
Mailing Address - Fax:
Practice Address - Street 1:622 SW ALDER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3616
Practice Address - Country:US
Practice Address - Phone:503-226-6791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0016100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist