Provider Demographics
NPI:1235434374
Name:JEONG, SUSAN (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JEONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6715 CLOVERDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 DOUGHTY BLVD
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-2050
Practice Address - Country:US
Practice Address - Phone:516-371-4113
Practice Address - Fax:516-371-4454
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0528791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist