Provider Demographics
NPI:1770264103
Name:KIM, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
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 1:100 COUNTY ROAD B W
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1931
Mailing Address - Country:US
Mailing Address - Phone:608-772-8773
Mailing Address - Fax:
Practice Address - Street 1:100 COUNTY ROAD B W
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55117-1931
Practice Address - Country:US
Practice Address - Phone:608-772-8773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-4988183500000X
MN126132183500000X
WI22263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist