Provider Demographics
NPI:1841755949
Name:SISOUK, KIM (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:SISOUK
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 1:6710 PORTREE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2933
Mailing Address - Country:US
Mailing Address - Phone:707-217-6997
Mailing Address - Fax:
Practice Address - Street 1:3480 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041-3104
Practice Address - Country:US
Practice Address - Phone:703-931-1333
Practice Address - Fax:844-411-6528
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100002630183500000X
MD24641183500000X
VA0202215342183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist