Provider Demographics
NPI:1902498017
Name:KIM, BILLY
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 BROAD AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1550
Mailing Address - Country:US
Mailing Address - Phone:201-367-9595
Mailing Address - Fax:201-367-9599
Practice Address - Street 1:263 BROAD AVE FL 1
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1550
Practice Address - Country:US
Practice Address - Phone:201-367-9595
Practice Address - Fax:201-367-9599
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03921000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist