Provider Demographics
NPI:1447769799
Name:KANG, CHRISTINE TAELIM
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:TAELIM
Last Name:KANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAELIM
Other - Middle Name:
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8507 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8507 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7342
Practice Address - Country:US
Practice Address - Phone:917-396-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist