Provider Demographics
NPI:1013504562
Name:MIN, JIN KI
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:KI
Last Name:MIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 ENGLISH LN APT 714
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-9136
Mailing Address - Country:US
Mailing Address - Phone:404-987-1360
Mailing Address - Fax:
Practice Address - Street 1:672 FURYS FERRY RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-8945
Practice Address - Country:US
Practice Address - Phone:706-210-7505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist