Healthcare Provider Details

I. General information

NPI: 1295323608
Provider Name (Legal Business Name): JUSTIN JIN RYU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2021
Last Update Date: 01/03/2021
Certification Date: 01/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CORINTH ST
ROSLINDALE MA
02131-3087
US

IV. Provider business mailing address

1 CORINTH ST
ROSLINDALE MA
02131-3087
US

V. Phone/Fax

Practice location:
  • Phone: 617-327-0210
  • Fax:
Mailing address:
  • Phone: 617-327-0210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH239195
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: