MEDICARE: DR. KIM SISOUK PHARMD

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	PH100002630	DC
2	183500000X	Pharmacist	24641	MD
3	183500000X	Pharmacist	0202215342	VA

General Provider Information

NPI Number	:	1841755949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM SISOUK PHARMD

Provider Business Mailing Address
First Line	:	6710 PORTREE CT
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22152-2933
Country	:	US
Telephone Number	:	707-217-6997
Fax Number	:

Provider Business Practice Location Address
First Line	:	3480 S JEFFERSON ST
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22041-3104
Country	:	US
Telephone Number	:	703-931-1333
Fax Number	:	844-411-6528

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

Provider Enumeration Date	:	02/04/2019
Last Update Date	:	11/03/2020

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Directions to “ DR. KIM SISOUK PHARMD” Practice Location

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