Provider Demographics
NPI:1871896928
Name:KIM, SUNG SOO (PHARMACIST)
Entity type:Individual
Prefix:DR
First Name:SUNG
Middle Name:SOO
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 EAGLE GLEN PKWY
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-0785
Mailing Address - Country:US
Mailing Address - Phone:951-847-8083
Mailing Address - Fax:
Practice Address - Street 1:2243 EAGLE GLEN PKWY
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883-0785
Practice Address - Country:US
Practice Address - Phone:951-847-8083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist