Provider Demographics
NPI:1649378274
Name:KIM, SUSAN TAEJA (PHARMACIST)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:TAEJA
Last Name:KIM
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 WINDING RIVER LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-3183
Mailing Address - Country:US
Mailing Address - Phone:610-935-3232
Mailing Address - Fax:
Practice Address - Street 1:1400 BLACKHORSE HILL RD
Practice Address - Street 2:PHARMACY(119)
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2040
Practice Address - Country:US
Practice Address - Phone:610-383-0282
Practice Address - Fax:610-383-0269
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048612-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist