Provider Demographics
NPI:1417138918
Name:CHIN, BONG (RPH)
Entity Type:Individual
Prefix:MR
First Name:BONG
Middle Name:
Last Name:CHIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ROUTE 303
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-5900
Mailing Address - Country:US
Mailing Address - Phone:845-268-4765
Mailing Address - Fax:
Practice Address - Street 1:133 ROUTE 303
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-5900
Practice Address - Country:US
Practice Address - Phone:845-268-4765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00540643Medicaid