Provider Demographics
NPI:1033509831
Name:KWON, GENE
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 ROBINSON PLACE CT
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7951 NOLPARK CT
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5205
Practice Address - Country:US
Practice Address - Phone:410-969-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-31
Last Update Date:2015-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT14897183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician