Healthcare Provider Details

I. General information

NPI: 1841700457
Provider Name (Legal Business Name): CHUL HAK GWAG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14429 NORTHERN BLVD
FLUSHING NY
11354-4230
US

IV. Provider business mailing address

10124 QUEENS BLVD APT 4A
FOREST HILLS NY
11375-2778
US

V. Phone/Fax

Practice location:
  • Phone: 718-886-6645
  • Fax:
Mailing address:
  • Phone: 909-993-7175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number063551
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: