Provider Demographics
NPI:1538570304
Name:KIM, DALE
Entity type:Individual
Prefix:
First Name:DALE
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 1:2403 W SPRINGFIELD AVE
Mailing Address - Street 2:W11
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2883
Mailing Address - Country:US
Mailing Address - Phone:847-422-3045
Mailing Address - Fax:
Practice Address - Street 1:3114 VILLAGE OFFICE PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7680
Practice Address - Country:US
Practice Address - Phone:217-378-4807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist