Provider Demographics
NPI:1487311098
Name:KIM, HAENA (RPH)
Entity type:Individual
Prefix:
First Name:HAENA
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 1:130 W HILL AVE APT 99
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2983
Mailing Address - Country:US
Mailing Address - Phone:510-789-9334
Mailing Address - Fax:
Practice Address - Street 1:130 W HILL AVE APT 99
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-2983
Practice Address - Country:US
Practice Address - Phone:510-789-9334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist