Provider Demographics
NPI:1750984639
Name:SHIM, JUSTIN (RPH)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:SHIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5844 203RD ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1648
Mailing Address - Country:US
Mailing Address - Phone:917-775-3995
Mailing Address - Fax:
Practice Address - Street 1:17005 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1347
Practice Address - Country:US
Practice Address - Phone:718-262-9533
Practice Address - Fax:718-262-9744
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067266183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist