Provider Demographics
NPI:1336596006
Name:KIM, SUJIN (PH60639568)
Entity type:Individual
Prefix:
First Name:SUJIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PH60639568
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 YAUGER WAY SW
Mailing Address - Street 2:UNIT B202
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:425-507-5078
Mailing Address - Fax:
Practice Address - Street 1:305 COOPER POINT RD NW
Practice Address - Street 2:#103
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4436
Practice Address - Country:US
Practice Address - Phone:360-754-8014
Practice Address - Fax:360-754-0778
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60639568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist