Provider Demographics
NPI:1275751620
Name:JUNG, CONNIE T (RPH, PHD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:T
Last Name:JUNG
Suffix:
Gender:F
Credentials:RPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 BALBOA DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-7453
Mailing Address - Country:US
Mailing Address - Phone:301-938-2702
Mailing Address - Fax:
Practice Address - Street 1:5600 FISHERS LN
Practice Address - Street 2:HF-11, ROOM 14C-03
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20857-0001
Practice Address - Country:US
Practice Address - Phone:301-827-5902
Practice Address - Fax:301-827-4774
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist