Provider Demographics
NPI:1083952741
Name:CHUNG, INSEON LIM (RPH)
Entity Type:Individual
Prefix:
First Name:INSEON
Middle Name:LIM
Last Name:CHUNG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 DESIRE AVE. #103
Mailing Address - Street 2:C/O NEW LIFE PHARMACY
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748
Mailing Address - Country:US
Mailing Address - Phone:626-839-3000
Mailing Address - Fax:626-521-5283
Practice Address - Street 1:1722 DESIRE AVE #103
Practice Address - Street 2:C/O NEW LIFE PHARMACY
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748
Practice Address - Country:US
Practice Address - Phone:626-839-3000
Practice Address - Fax:626-521-5283
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CL302AMedicare UPIN