Provider Demographics
NPI:1164735288
Name:KWAK, JINWOO
Entity Type:Individual
Prefix:
First Name:JINWOO
Middle Name:
Last Name:KWAK
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 1:11800 ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-4003
Mailing Address - Country:US
Mailing Address - Phone:562-924-7718
Mailing Address - Fax:
Practice Address - Street 1:11800 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-4003
Practice Address - Country:US
Practice Address - Phone:562-924-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-18
Last Update Date:2010-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist