=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316660640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HYUNG KYU KIM PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W 16TH ST
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-2745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-584-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4015 AUTUMN HEIGHTS DR UNIT B
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-5904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-493-8480
-----------------------------------------------------
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 | 0024214
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------