Provider Demographics
NPI:1316057243
Name:KIM, GENE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GENE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4228
Mailing Address - Country:US
Mailing Address - Phone:951-654-9393
Mailing Address - Fax:951-654-9394
Practice Address - Street 1:100 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4228
Practice Address - Country:US
Practice Address - Phone:951-654-9393
Practice Address - Fax:951-654-9394
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA463750Medicaid