MEDICARE: KEUN CHUL KIM

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	RPH81879	CA

General Provider Information

NPI Number	:	1417587700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEUN CHUL KIM

Provider Business Mailing Address
First Line	:	415 ESTHER PL
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-5139
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20627 GOLDEN SPRINGS DR
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91789-4814
Country	:	US
Telephone Number	:	909-839-0001
Fax Number	:

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

Provider Enumeration Date	:	01/25/2020
Last Update Date	:	01/25/2020

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