Healthcare Provider Details

I. General information

NPI: 1710617121
Provider Name (Legal Business Name): KWONG LUN YIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 E BASELINE RD
PHOENIX AZ
85042-6947
US

IV. Provider business mailing address

15801 S 48TH ST APT 1106
PHOENIX AZ
85048-0835
US

V. Phone/Fax

Practice location:
  • Phone: 602-305-4421
  • Fax: 602-305-4423
Mailing address:
  • Phone: 909-516-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS011432
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberI025585
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: