Provider Demographics
NPI:1053925065
Name:KIM, SUNGHA
Entity type:Individual
Prefix:
First Name:SUNGHA
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 1:703 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2800
Practice Address - Country:US
Practice Address - Phone:641-428-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122984183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist