Provider Demographics
NPI:1568987139
Name:KIM, EUN TAE (REGISTEREDPHARMACIST)
Entity type:Individual
Prefix:
First Name:EUN TAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:REGISTEREDPHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 WHITTIER BLVD RM 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-2440
Mailing Address - Country:US
Mailing Address - Phone:323-307-0470
Mailing Address - Fax:323-307-0495
Practice Address - Street 1:111 S SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-6736
Practice Address - Country:US
Practice Address - Phone:760-327-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist