Provider Demographics
NPI:1518780881
Name:KIM, KYEONGHWA
Entity type:Individual
Prefix:
First Name:KYEONGHWA
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 1:151 LOHS PL
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07640-1047
Mailing Address - Country:US
Mailing Address - Phone:201-341-6677
Mailing Address - Fax:
Practice Address - Street 1:225 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1523
Practice Address - Country:US
Practice Address - Phone:201-775-7051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03480800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist