Provider Demographics
NPI:1154371268
Name:SOON YOUNG YIM
Entity type:Organization
Organization Name:SOON YOUNG YIM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOON YOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:YIM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:213-381-7705
Mailing Address - Street 1:2681 W OLYMPIC BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2681 W OLYMPIC BLVD
Practice Address - Street 2:STE 102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2810
Practice Address - Country:US
Practice Address - Phone:213-381-7705
Practice Address - Fax:213-381-7706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY469313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5614397OtherOTHER ID NUMBER
CAPHA469310Medicaid
5614397OtherOTHER ID NUMBER