Provider Demographics
NPI:1780128637
Name:KIM, JOHNNY (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3721
Mailing Address - Country:US
Mailing Address - Phone:516-234-3021
Mailing Address - Fax:
Practice Address - Street 1:55 WATER ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10041-0004
Practice Address - Country:US
Practice Address - Phone:347-774-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03820700183500000X
NY062513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist