Provider Demographics
NPI:1366928178
Name:KIM, SANG
Entity type:Individual
Prefix:
First Name:SANG
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 1:8867 LADUE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2045
Mailing Address - Country:US
Mailing Address - Phone:314-725-3264
Mailing Address - Fax:
Practice Address - Street 1:8867 LADUE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2045
Practice Address - Country:US
Practice Address - Phone:314-725-3264
Practice Address - Fax:314-725-8534
Is Sole Proprietor?:No
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015020759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist