Provider Demographics
NPI:1013321108
Name:KIM, ELLEN (RPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 A CENTENNIAL LANE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042
Mailing Address - Country:US
Mailing Address - Phone:410-750-9439
Mailing Address - Fax:410-750-8879
Practice Address - Street 1:3300 CENTENNIAL LN
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3600
Practice Address - Country:US
Practice Address - Phone:410-750-9439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist