Provider Demographics
NPI:1083983761
Name:KOH, CHARLES CHANG YOUNG
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CHANG YOUNG
Last Name:KOH
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 1:19522 CLEVELAND BAY LN
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-7923
Mailing Address - Country:US
Mailing Address - Phone:714-322-2138
Mailing Address - Fax:
Practice Address - Street 1:475 HIDDEN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-3972
Practice Address - Country:US
Practice Address - Phone:951-280-1270
Practice Address - Fax:951-280-1276
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-24
Last Update Date:2011-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist