Provider Demographics
NPI:1114641644
Name:KIM, EUN DAM (RPH)
Entity type:Individual
Prefix:MS
First Name:EUN DAM
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21923 67TH AVE APT B
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2649
Mailing Address - Country:US
Mailing Address - Phone:347-738-1255
Mailing Address - Fax:
Practice Address - Street 1:19301 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:NY
Practice Address - Zip Code:11358-2935
Practice Address - Country:US
Practice Address - Phone:347-738-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist