=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013504562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIN KI MIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2020
-----------------------------------------------------
Last Update Date | 12/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 672 FURYS FERRY RD
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907-8945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-210-7505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3010 ENGLISH LN APT 714
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-9136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-987-1360
-----------------------------------------------------
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 | RPH032470
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------