Healthcare Provider Details

I. General information

NPI: 1235434374
Provider Name (Legal Business Name): SUSAN JEONG RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 DOUGHTY BLVD
INWOOD NY
11096-2050
US

IV. Provider business mailing address

6715 CLOVERDALE BLVD
OAKLAND GARDENS NY
11364-2742
US

V. Phone/Fax

Practice location:
  • Phone: 516-371-4113
  • Fax: 516-371-4454
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0528791
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: