Provider Demographics
NPI:1184940835
Name:KIM, HAKSOO
Entity type:Individual
Prefix:MR
First Name:HAKSOO
Middle Name:
Last Name:KIM
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 1:22346 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1817
Mailing Address - Country:US
Mailing Address - Phone:245-542-1925
Mailing Address - Fax:245-542-7025
Practice Address - Street 1:22346 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1817
Practice Address - Country:US
Practice Address - Phone:248-542-1925
Practice Address - Fax:248-542-7025
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist