MEDICARE: TAE RYONG CHONG PHARMD

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	54784	CA

General Provider Information

NPI Number	:	1659828937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAE RYONG CHONG PHARMD

Provider Business Mailing Address
First Line	:	3060 GLENDALE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1829
Country	:	US
Telephone Number	:	323-666-8932
Fax Number	:

Provider Business Practice Location Address
First Line	:	3060 GLENDALE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1829
Country	:	US
Telephone Number	:	323-666-8932
Fax Number	:

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

Provider Enumeration Date	:	09/05/2016
Last Update Date	:	09/28/2016

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