Provider Demographics
NPI:1912331026
Name:KIM, HAK KYOUNG
Entity type:Individual
Prefix:
First Name:HAK KYOUNG
Middle Name:
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 1:3814 PRUNERIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5846
Mailing Address - Country:US
Mailing Address - Phone:201-966-4916
Mailing Address - Fax:
Practice Address - Street 1:19250A 71ST CRES
Practice Address - Street 2:APT 1B
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-4014
Practice Address - Country:US
Practice Address - Phone:201-966-4916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78286183500000X
NY058421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist