Provider Demographics
NPI:1144555954
Name:KIM, YOUNG WAN (PHARM D)
Entity type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:WAN
Last Name:KIM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LAKEVILLE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1101
Mailing Address - Country:US
Mailing Address - Phone:516-465-5250
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1101
Practice Address - Country:US
Practice Address - Phone:516-465-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053776183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist