Provider Demographics
NPI:1407068372
Name:CHANG, KWANG-SOOK (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KWANG-SOOK
Middle Name:
Last Name:CHANG
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 1:21 CAMBORNE CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-8918
Mailing Address - Country:US
Mailing Address - Phone:585-377-1896
Mailing Address - Fax:585-377-1896
Practice Address - Street 1:3220 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-4608
Practice Address - Country:US
Practice Address - Phone:585-383-1630
Practice Address - Fax:585-383-1425
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01934849Medicaid