Healthcare Provider Details

I. General information

NPI: 1356067185
Provider Name (Legal Business Name): JENNY KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10889 WELLWORTH AVE
LOS ANGELES CA
90024-4918
US

IV. Provider business mailing address

1246 BROCKTON AVE APT 3
LOS ANGELES CA
90025-1350
US

V. Phone/Fax

Practice location:
  • Phone: 310-474-2152
  • Fax:
Mailing address:
  • Phone: 310-408-7709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number86864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: