Provider Demographics
NPI:1083690911
Name:HYUNGWON KANG
Entity Type:Organization
Organization Name:HYUNGWON KANG
Other - Org Name:CORNER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PIC
Authorized Official - Prefix:
Authorized Official - First Name:HYUNGWON
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-622-0688
Mailing Address - Street 1:2550 PLEASANT HILL RD # BUILD100
Mailing Address - Street 2:STE 126
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4122
Mailing Address - Country:US
Mailing Address - Phone:770-622-0688
Mailing Address - Fax:770-622-0689
Practice Address - Street 1:2550 PLEASANT HILL RD # BUILD100
Practice Address - Street 2:STE 126
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4122
Practice Address - Country:US
Practice Address - Phone:770-622-0688
Practice Address - Fax:770-622-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0089943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA422771904AMedicaid
1153864OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1153864OtherNCPDP PROVIDER IDENTIFICATION NUMBER