Provider Demographics
NPI:1831725167
Name:LIM, JAE
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:LIM
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 1:1721 SAILS WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-2072
Mailing Address - Country:US
Mailing Address - Phone:615-720-2302
Mailing Address - Fax:
Practice Address - Street 1:6005 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6346
Practice Address - Country:US
Practice Address - Phone:865-588-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN41630183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No333600000XSuppliersPharmacy