Provider Demographics
NPI:1386764934
Name:KIM, MIKE S (PHARMD)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:S
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 1:25965 NORMANDIE AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3416
Mailing Address - Country:US
Mailing Address - Phone:424-328-2110
Mailing Address - Fax:
Practice Address - Street 1:25965 NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3416
Practice Address - Country:US
Practice Address - Phone:424-328-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00053747183500000X
CARPH 54484183500000X
COPHA - 15953183500000X
HIPH - 2208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist