=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265854566
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KI-POONG KIM PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2014
-----------------------------------------------------
Last Update Date | 01/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20300 W COUNTRY CLUB DR APT 109
-----------------------------------------------------
City | AVENTURA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33180-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-466-7857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20300 W COUNTRY CLUB DR APT 109
-----------------------------------------------------
City | AVENTURA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33180-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-466-7857
-----------------------------------------------------
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 | PS50397
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------