Healthcare Provider Details

I. General information

NPI: 1619475167
Provider Name (Legal Business Name): JAYE KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE
MORENO VALLEY CA
92555-3927
US

IV. Provider business mailing address

1019 ACERO ST
CHULA VISTA CA
91910-8018
US

V. Phone/Fax

Practice location:
  • Phone: 951-486-4000
  • Fax:
Mailing address:
  • Phone: 858-366-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number76772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: