Provider Demographics
NPI:1144406281
Name:JEON, JAE WOO (RPH)
Entity Type:Individual
Prefix:
First Name:JAE WOO
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 RICHMOND HILL RD APT 3H
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-7807
Mailing Address - Country:US
Mailing Address - Phone:646-322-0199
Mailing Address - Fax:
Practice Address - Street 1:802 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4204
Practice Address - Country:US
Practice Address - Phone:718-604-2585
Practice Address - Fax:718-604-2587
Is Sole Proprietor?:No
Enumeration Date:2008-01-19
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist