Healthcare Provider Details

I. General information

NPI: 1649293697
Provider Name (Legal Business Name): MINAH KIM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E CALIFORNIA BLVD SUITE 103
PASADENA CA
91105-3954
US

IV. Provider business mailing address

55 E CALIFORNIA BLVD SUITE 103
PASADENA CA
91105-3954
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-5956
  • Fax: 626-795-4998
Mailing address:
  • Phone: 626-795-5956
  • Fax: 626-795-4998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY47497
License Number StateCA

VIII. Authorized Official

Name: DR. MINAH KIM
Title or Position: OWNER
Credential: PHARM. D.
Phone: 626-795-5956