MEDICARE: KIM SON PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0578522	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1578642245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIM SON PHARMACY

Provider Business Mailing Address
First Line	:	625 E VALLEY BLVD
Second Line	:	STE J
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3591
Country	:	US
Telephone Number	:	626-571-5967
Fax Number	:	626-571-5968

Provider Business Practice Location Address
First Line	:	625 E VALLEY BLVD
Second Line	:	SUITE J
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-3591
Country	:	US
Telephone Number	:	626-571-5967
Fax Number	:	626-571-5968

Authorized Official
Title or Position	:	PIC
Name	:	KIM CHI NGUYEN
Credential	:
Telephone Number	:	626-571-5967

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	02/19/2009

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Directions to “KIM SON PHARMACY ” Practice Location

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