Healthcare Provider Details

I. General information

NPI: 1588850341
Provider Name (Legal Business Name): HENRY KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5006 MONTGOMERY RD
ELLICOTT CITY MD
21043-6719
US

IV. Provider business mailing address

5006 MONTGOMERY RD
ELLICOTT CITY MD
21043-6719
US

V. Phone/Fax

Practice location:
  • Phone: 516-851-7601
  • Fax:
Mailing address:
  • Phone: 516-851-7601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02470
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19332
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202210523
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number40044
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number040538
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number58095
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: