Provider Demographics
NPI:1295107605
Name:KIM, SAMUEL (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E LATHAM AVE STE P
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4435
Mailing Address - Country:US
Mailing Address - Phone:951-658-7111
Mailing Address - Fax:951-658-7113
Practice Address - Street 1:1001 E LATHAM AVE STE P
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4435
Practice Address - Country:US
Practice Address - Phone:951-658-7111
Practice Address - Fax:951-658-7113
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-24
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist