Provider Demographics
NPI:1093274128
Name:SHIN, KWANGSUN CHUN
Entity Type:Individual
Prefix:
First Name:KWANGSUN
Middle Name:CHUN
Last Name:SHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15074 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1301
Mailing Address - Country:US
Mailing Address - Phone:562-902-5580
Mailing Address - Fax:562-902-5589
Practice Address - Street 1:15074 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1301
Practice Address - Country:US
Practice Address - Phone:562-902-5580
Practice Address - Fax:562-902-5589
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY465633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy