Healthcare Provider Details

I. General information

NPI: 1750554739
Provider Name (Legal Business Name): MRS. JUNGRIM SEO KANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 LARKFIELD ROAD
EAST NORTHPORT NY
11731
US

IV. Provider business mailing address

56 ROFAY DRIVE
EAST NORTHPORT NY
11731
US

V. Phone/Fax

Practice location:
  • Phone: 631-368-0100
  • Fax:
Mailing address:
  • Phone: 631-462-0844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number044312
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: