Healthcare Provider Details

I. General information

NPI: 1316856719
Provider Name (Legal Business Name): JAEWON KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SUMMIT AVE
MONTVALE NJ
07645-1523
US

IV. Provider business mailing address

56 BROWNSTONE WAY APT 414
ENGLEWOOD NJ
07631-1224
US

V. Phone/Fax

Practice location:
  • Phone: 201-472-5431
  • Fax:
Mailing address:
  • Phone: 201-969-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04110500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: