Provider Demographics
NPI:1730407792
Name:KIM, CHUNG W (RPH)
Entity type:Individual
Prefix:
First Name:CHUNG
Middle Name:W
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 1:19195 BURNT BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-1267
Mailing Address - Country:US
Mailing Address - Phone:571-223-1086
Mailing Address - Fax:
Practice Address - Street 1:448 S KING ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3619
Practice Address - Country:US
Practice Address - Phone:703-777-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist