Provider Demographics
NPI:1972045565
Name:KIM, KI BONG (PHARMD)
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:BONG
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:KAI
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4025 DELRIDGE WAY SW
Mailing Address - Street 2:#400
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-1249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4025 DELRIDGE WAY SW
Practice Address - Street 2:#400
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-1249
Practice Address - Country:US
Practice Address - Phone:206-763-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60667242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist