Provider Demographics
NPI:1356623193
Name:KIM, JO SEUNG
Entity type:Individual
Prefix:MR
First Name:JO
Middle Name:SEUNG
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 1:2721 HEATHROW DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8172
Mailing Address - Country:US
Mailing Address - Phone:678-455-4544
Mailing Address - Fax:678-455-7201
Practice Address - Street 1:2595 PEACHTREE PKWY
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7223
Practice Address - Country:US
Practice Address - Phone:678-455-4544
Practice Address - Fax:678-455-7201
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist