Provider Demographics
NPI:1992308886
Name:PENG, KIM (RPH)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PENG
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 1:490 N BROAD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4321
Mailing Address - Country:US
Mailing Address - Phone:215-430-5757
Mailing Address - Fax:
Practice Address - Street 1:490 N BROAD ST STE 100
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-4321
Practice Address - Country:US
Practice Address - Phone:215-430-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist