Provider Demographics
NPI:1861643082
Name:KIM, REBECCA KYUNG-NAN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:KYUNG-NAN
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 CRETE CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4751
Mailing Address - Country:US
Mailing Address - Phone:951-776-1312
Mailing Address - Fax:951-776-1312
Practice Address - Street 1:3865 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3919
Practice Address - Country:US
Practice Address - Phone:951-352-5336
Practice Address - Fax:951-352-5315
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist