Healthcare Provider Details

I. General information

NPI: 1407750029
Provider Name (Legal Business Name): JASON KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W COLLEGE ST
GRAPEVINE TX
76051-3565
US

IV. Provider business mailing address

1650 W COLLEGE ST
GRAPEVINE TX
76051-3565
US

V. Phone/Fax

Practice location:
  • Phone: 817-481-1588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60752
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: