MEDICARE: MR. KYUNG MO KIM RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051.040727	IL

General Provider Information

NPI Number	:	1003198672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYUNG MO KIM RPH

Provider Business Mailing Address
First Line	:	515 S CAROL LN
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-3505
Country	:	US
Telephone Number	:	847-997-5475
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 W NORTH AVE
Second Line	:
City	:	MELROSE PARK
State	:	IL
Zip	:	60160-1413
Country	:	US
Telephone Number	:	708-345-6080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2011
Last Update Date	:	09/09/2011

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