Provider Demographics
NPI:1366704231
Name:KIM, SANDY SONG (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SANDY
Middle Name:SONG
Last Name:KIM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27107 TOURNEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-1904
Mailing Address - Country:US
Mailing Address - Phone:661-222-2134
Mailing Address - Fax:
Practice Address - Street 1:1985 ZONAL AVE
Practice Address - Street 2:PSC B-15
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-1904
Practice Address - Country:US
Practice Address - Phone:818-903-5422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist