Provider Demographics
NPI:1720525660
Name:KIM, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
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 1:704 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-3757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 LEMOINE AVE
Practice Address - Street 2:#1
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5651
Practice Address - Country:US
Practice Address - Phone:201-461-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03751900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist