=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811299217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYUNG JIN KIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2010
-----------------------------------------------------
Last Update Date | 11/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7414 LITTLE RIVER TPKE
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-269-1955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7606 JAMES MADISON HWY
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-1916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-628-1533
-----------------------------------------------------
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 | 0202207620
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------