Healthcare Provider Details

I. General information

NPI: 1417883760
Provider Name (Legal Business Name): SO H KIM
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5832 BEACH BLVD
BUENA PARK CA
90621-2010
US

IV. Provider business mailing address

5832 BEACH BLVD
BUENA PARK CA
90621-2010
US

V. Phone/Fax

Practice location:
  • Phone: 714-852-8050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: