Provider Demographics
NPI:1144760034
Name:KIM, SONG TAK
Entity type:Individual
Prefix:DR
First Name:SONG TAK
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:SONG
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:10800 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3043
Mailing Address - Country:US
Mailing Address - Phone:951-353-3228
Mailing Address - Fax:
Practice Address - Street 1:10800 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3043
Practice Address - Country:US
Practice Address - Phone:951-353-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist