Provider Demographics
NPI:1073619326
Name:KWON, AUSTIN
Entity Type:Individual
Prefix:
First Name:AUSTIN
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 1:6911 CEDROS AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3849
Mailing Address - Country:US
Mailing Address - Phone:818-891-7711
Mailing Address - Fax:
Practice Address - Street 1:16111 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:SEPULVEDA
Practice Address - State:CA
Practice Address - Zip Code:91343-2036
Practice Address - Country:US
Practice Address - Phone:818-891-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417851835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy