Provider Demographics
NPI:1265756928
Name:KIM, JOANN HJ
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:HJ
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 SUNRISE HWY
Mailing Address - Street 2:TARGET-1148
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5908
Mailing Address - Country:US
Mailing Address - Phone:631-969-8970
Mailing Address - Fax:
Practice Address - Street 1:838 SUNRISE HWY
Practice Address - Street 2:TARGET-1148
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5908
Practice Address - Country:US
Practice Address - Phone:631-969-8970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist