Provider Demographics
NPI:1003419516
Name:HONG, BONGSU KANG
Entity Type:Individual
Prefix:
First Name:BONGSU
Middle Name:KANG
Last Name:HONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4853
Mailing Address - Country:US
Mailing Address - Phone:770-418-0510
Mailing Address - Fax:
Practice Address - Street 1:4110 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4853
Practice Address - Country:US
Practice Address - Phone:770-418-0510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH025881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist