Healthcare Provider Details

I. General information

NPI: 1033950878
Provider Name (Legal Business Name): DAGAM JEONG PHARMD, BCOP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 BROOKLINE AVE
BOSTON MA
02215-5450
US

IV. Provider business mailing address

450 BROOKLINE AVE YC-538K
BOSTON MA
02215-5450
US

V. Phone/Fax

Practice location:
  • Phone: 617-632-2410
  • Fax:
Mailing address:
  • Phone: 617-632-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number071493
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License NumberPH1002184
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRPH06534
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH1002184
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPH1002184
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: