Healthcare Provider Details

I. General information

NPI: 1073127973
Provider Name (Legal Business Name): HANEUL JUDY KWON RPH, PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 ALBANY POST RD
MONTROSE NY
10548-1454
US

IV. Provider business mailing address

15024 12TH AVE
WHITESTONE NY
11357-1808
US

V. Phone/Fax

Practice location:
  • Phone: 914-737-4400
  • Fax:
Mailing address:
  • Phone: 917-683-5966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH239690
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH239690
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: