=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326522145
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEUNG EUN KIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2018
-----------------------------------------------------
Last Update Date | 02/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1424 BERGEN BLVD
-----------------------------------------------------
City | FORT LEE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07024-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-482-0801
-----------------------------------------------------
Fax | 201-331-1444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1424 BERGEN BLVD
-----------------------------------------------------
City | FORT LEE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07024-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-482-0801
-----------------------------------------------------
Fax | 201-331-1444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28RI03966600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------