Healthcare Provider Details

I. General information

NPI: 1689428997
Provider Name (Legal Business Name): JUNG SU RYU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HWY 80 W
CLINTON MS
39056
US

IV. Provider business mailing address

204 HWY 80 W
CLINTON MS
39056
US

V. Phone/Fax

Practice location:
  • Phone: 601-926-1179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-101448
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: