Active NPI
Jack Kim
- Pharmacist
- Maplewood, MN
National Provider Identifier
1770264103
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 126132
- Practice address
- 100 County Road B W
Maplewood, MN 55117-1931 - Phone
- (608) 772-8773
- NPI assigned
- Jul 27, 2023
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | PH-4988 | HI | |
| Pharmacist | 183500000X | 126132 | MN | Primary |
| Pharmacist | 183500000X | 22263 | WI |
Addresses
Primary practice location
100 County Road B W
Maplewood, MN 55117-1931
Mailing address
100 County Road B W
Maplewood, MN 55117-1931
Phone (608) 772-8773
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PH-4988 | HI | MD | Pharmacist |
| 126132 | MN | MD | Pharmacist |
| 22263 | WI | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1690416000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1724803200000",
"number": "1770264103",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "100 COUNTY ROAD B W",
"city": "MAPLEWOOD",
"state": "MN",
"postal_code": "551171931",
"telephone_number": "608-772-8773"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "100 COUNTY ROAD B W",
"city": "MAPLEWOOD",
"state": "MN",
"postal_code": "551171931",
"telephone_number": "608-772-8773"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KIM",
"first_name": "JACK",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2023-07-27",
"last_updated": "2024-08-28",
"certification_date": "2024-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "HI",
"license": "PH-4988",
"primary": false
},
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "MN",
"license": "126132",
"primary": true
},
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "WI",
"license": "22263",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Maplewood, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.