Healthcare Provider Details

I. General information

NPI: 1265206718
Provider Name (Legal Business Name): STEFFANIE SANG MOUY UNG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 N GRAND AVE
GLENDORA CA
91741-2434
US

IV. Provider business mailing address

230 W GLADSTONE ST
SAN DIMAS CA
91773-1810
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-0385
  • Fax:
Mailing address:
  • Phone: 626-627-4068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number88832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: