Provider Demographics
NPI:1013903475
Name:KIM, JASON MYUNGJOON (RPH)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:MYUNGJOON
Last Name:KIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8227 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-5426
Mailing Address - Country:US
Mailing Address - Phone:818-989-2333
Mailing Address - Fax:818-989-2675
Practice Address - Street 1:8227 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5426
Practice Address - Country:US
Practice Address - Phone:818-989-2333
Practice Address - Fax:818-989-2675
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 39008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA451710Medicaid
CAPHA451710Medicaid