Provider Demographics
NPI:1043490642
Name:KONG, JI-HEUN JONATHAN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:JI-HEUN
Middle Name:JONATHAN
Last Name:KONG
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7814 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2952
Mailing Address - Country:US
Mailing Address - Phone:718-578-7253
Mailing Address - Fax:
Practice Address - Street 1:4602 GREENPOINT AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-1708
Practice Address - Country:US
Practice Address - Phone:718-784-0070
Practice Address - Fax:718-784-0025
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00267625Medicaid