=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598539389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAE HYUN KANG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2023
-----------------------------------------------------
Last Update Date | 11/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 397 BOSTON POST RD
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02493-1587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-894-3785
-----------------------------------------------------
Fax | 781-899-5860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 397 BOSTON POST RD
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02493-1587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-894-3785
-----------------------------------------------------
Fax | 781-899-5860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH997021
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------