MEDICARE: HEASOOK KWON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	053278	NY

General Provider Information

NPI Number	:	1528382280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEASOOK KWON

Provider Business Mailing Address
First Line	:	1831 GRAND CONCOURSE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-6323
Country	:	US
Telephone Number	:	718-466-1000
Fax Number	:	718-466-1006

Provider Business Practice Location Address
First Line	:	1831 GRAND CONCOURSE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-6323
Country	:	US
Telephone Number	:	718-466-1000
Fax Number	:	718-466-1006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2010
Last Update Date	:	04/22/2013

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