Provider Demographics
NPI:1003851320
Name:SOON R CHUNG
Entity Type:Organization
Organization Name:SOON R CHUNG
Other - Org Name:GARDENA MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:310-515-6570
Mailing Address - Street 1:1045 W REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4128
Mailing Address - Country:US
Mailing Address - Phone:310-515-6570
Mailing Address - Fax:310-515-6549
Practice Address - Street 1:1045 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4128
Practice Address - Country:US
Practice Address - Phone:310-515-6570
Practice Address - Fax:310-515-6549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAPHY487643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0570158OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FG0639419OtherDEA
0570158OtherNCPDP PROVIDER IDENTIFICATION NUMBER