MEDICARE: KIMS MODERN PHARMACY INC

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	333600000X	Pharmacy	054006861	IL
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1440522	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1285746123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIMS MODERN PHARMACY INC

Provider Business Mailing Address
First Line	:	3432 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5117
Country	:	US
Telephone Number	:	773-588-6055
Fax Number	:	773-588-5005

Provider Business Practice Location Address
First Line	:	3432 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5117
Country	:	US
Telephone Number	:	773-588-6055
Fax Number	:	773-588-5005

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. NAMIL KIM
Credential	:
Telephone Number	:	773-588-6055

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	11/24/2008

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