MEDICARE: KYUNGSUN JEONG 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	58905541701	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	58905541701	OTHER	UT	UTAH DEPARTMENT OF COMMERCE FOR PHARMACY

General Provider Information

NPI Number	:	1619245529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYUNGSUN JEONG KIM PHARM D

Provider Business Mailing Address
First Line	:	5353 S 960 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-3569
Country	:	US
Telephone Number	:	801-288-0413
Fax Number	:	801-288-2485

Provider Business Practice Location Address
First Line	:	5353 S 960 E
Second Line	:	#103
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-3569
Country	:	US
Telephone Number	:	801-288-4013
Fax Number	:	801-288-2485

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

Provider Enumeration Date	:	12/06/2011
Last Update Date	:	12/06/2011

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Directions to “ KYUNGSUN JEONG KIM PHARM D” Practice Location

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