=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235721846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARRISON KIM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2021
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6802 MYRTLE AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-7235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-456-1165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21923 67TH AVE APT B
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11364-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-750-9953
-----------------------------------------------------
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 | I066614
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------