Provider Demographics
NPI:1437142981
Name:SOON R. CHUNG
Entity Type:Organization
Organization Name:SOON R. CHUNG
Other - Org Name:GRAND AVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SOON
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:213-746-4114
Mailing Address - Street 1:1400 S GRAND AVE
Mailing Address - Street 2:#100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3048
Mailing Address - Country:US
Mailing Address - Phone:213-746-4114
Mailing Address - Fax:213-746-4465
Practice Address - Street 1:1400 S GRAND AVE
Practice Address - Street 2:#100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3048
Practice Address - Country:US
Practice Address - Phone:213-746-4114
Practice Address - Fax:213-746-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46585333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5615971OtherNCPDP
CAPHA465850Medicaid
BG8722921OtherDEA
CAPHA465850Medicaid