Healthcare Provider Details

I. General information

NPI: 1275200222
Provider Name (Legal Business Name): DONGKOO KHANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 E WINE COUNTRY RD
GRANDVIEW WA
98930-1062
US

IV. Provider business mailing address

610 E WINE COUNTRY RD
GRANDVIEW WA
98930-1062
US

V. Phone/Fax

Practice location:
  • Phone: 509-882-1060
  • Fax:
Mailing address:
  • Phone: 509-882-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberIR61182985
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: