Provider Demographics
NPI:1831785252
Name:KIM WILSON, HEEJOO (PHARMD)
Entity type:Individual
Prefix:
First Name:HEEJOO
Middle Name:
Last Name:KIM WILSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MARKET PLACE CIR # 137
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-7205
Mailing Address - Country:US
Mailing Address - Phone:859-797-8487
Mailing Address - Fax:
Practice Address - Street 1:240 WAL MART WAY
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-7516
Practice Address - Country:US
Practice Address - Phone:606-759-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist