MEDICARE: ELLEN 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	RP447599	PA
2	183500000X	Pharmacist	28R103532100	NJ

General Provider Information

NPI Number	:	1982044806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN KIM

Provider Business Mailing Address
First Line	:	164 W CHELTEN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3302
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	164 W CHELTEN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3302
Country	:	US
Telephone Number	:	215-438-5167
Fax Number	:

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

Provider Enumeration Date	:	06/25/2013
Last Update Date	:	06/25/2013

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Directions to “ ELLEN KIM ” Practice Location

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