=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871713719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCUS KIM PHARM D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 S WAUKEGAN RD
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-498-4151
-----------------------------------------------------
Fax | 847-498-9864
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 S WAUKEGAN RD
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-498-4151
-----------------------------------------------------
Fax | 847-498-9864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 51287921
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------