Provider Demographics
NPI:1902492689
Name:KIM, YI SEUL
Entity Type:Individual
Prefix:
First Name:YI SEUL
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 1:1 BERGEN ST APT 133
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-3197
Mailing Address - Country:US
Mailing Address - Phone:224-456-9604
Mailing Address - Fax:
Practice Address - Street 1:385 TREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1023
Practice Address - Country:US
Practice Address - Phone:973-676-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist