Provider Demographics
NPI:1902344815
Name:KIM, SU (RPH)
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:
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 1:2200 E GONZALES RD
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-0619
Mailing Address - Country:US
Mailing Address - Phone:805-278-5900
Mailing Address - Fax:
Practice Address - Street 1:2200 E GONZALES RD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0619
Practice Address - Country:US
Practice Address - Phone:805-278-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist