Provider Demographics
NPI:1679278444
Name:KIM, CHUNG EUN
Entity type:Individual
Prefix:
First Name:CHUNG EUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:CHUNGEUN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:2597 SARATOGA DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4211
Mailing Address - Country:US
Mailing Address - Phone:714-313-8896
Mailing Address - Fax:
Practice Address - Street 1:3303 HARBOR BLVD STE C2
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1518
Practice Address - Country:US
Practice Address - Phone:714-545-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist