MEDICARE: LISA 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	051298112	IL

General Provider Information

NPI Number	:	1700288305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA YOUNG KIM PHARM.D.

Provider Business Mailing Address
First Line	:	2100 VALENCIA DR APT 305
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-7088
Country	:	US
Telephone Number	:	217-721-3991
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 VALENCIA DR APT 305
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-7088
Country	:	US
Telephone Number	:	217-721-3991
Fax Number	:

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

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	09/25/2014

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