Provider Demographics
NPI:1316044159
Name:KWANGSUN C SHIN
Entity Type:Organization
Organization Name:KWANGSUN C SHIN
Other - Org Name:IMPERIAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER & PIC
Authorized Official - Prefix:
Authorized Official - First Name:KWANGSUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-902-5580
Mailing Address - Street 1:15074 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1301
Mailing Address - Country:US
Mailing Address - Phone:562-902-5580
Mailing Address - Fax:562-902-5589
Practice Address - Street 1:15074 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1301
Practice Address - Country:US
Practice Address - Phone:562-902-5580
Practice Address - Fax:562-902-5589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY465633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2112601OtherPK
CAPHA465630Medicaid
2112601OtherPK