Provider Demographics
NPI:1912078528
Name:KIM, SANDRA LEE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 W BARRY AVE APT 12B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5474
Mailing Address - Country:US
Mailing Address - Phone:734-945-8154
Mailing Address - Fax:
Practice Address - Street 1:833 S WOOD ST
Practice Address - Street 2:ROOM 164
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7229
Practice Address - Country:US
Practice Address - Phone:312-996-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL51291282183500000X
MI5302033788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist