Provider Demographics
NPI:1194031500
Name:JEON, MIJI
Entity Type:Individual
Prefix:MRS
First Name:MIJI
Middle Name:
Last Name:JEON
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 1:1511 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-2206
Mailing Address - Country:US
Mailing Address - Phone:714-655-5366
Mailing Address - Fax:
Practice Address - Street 1:1511 TOWER DR
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-2206
Practice Address - Country:US
Practice Address - Phone:714-655-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03277100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist