=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003306077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SO JUNG KIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2018
-----------------------------------------------------
Last Update Date | 10/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9010 MARKET PL
-----------------------------------------------------
City | LAKE STEVENS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98258-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-334-4028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10711 8TH AVE NE UNIT 519
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98125-6370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-987-3624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH61461853
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------