MEDICARE: JAE YOUNG KIM PHARM. D.

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	19825	CO
2	183500000X	Pharmacist	22534	NC
3	183500000X	Pharmacist	71953	CA

General Provider Information

NPI Number	:	1235473174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAE YOUNG KIM PHARM. D.

Provider Business Mailing Address
First Line	:	16830 SAN FERNANDO MISSION BLVD
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-4247
Country	:	US
Telephone Number	:	818-831-5059
Fax Number	:	818-832-6541

Provider Business Practice Location Address
First Line	:	16830 SAN FERNANDO MISSION BLVD
Second Line	:
City	:	GRANADA HILLS
State	:	CA
Zip	:	91344-4247
Country	:	US
Telephone Number	:	818-831-5059
Fax Number	:	818-832-6541

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

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	03/14/2019

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