Provider Demographics
NPI:1497425227
Name:JIN, DAE HYUN (RPH)
Entity Type:Individual
Prefix:
First Name:DAE HYUN
Middle Name:
Last Name:JIN
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 1:100 LORENZ RD APT 907
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-2504
Mailing Address - Country:US
Mailing Address - Phone:512-820-8997
Mailing Address - Fax:
Practice Address - Street 1:2500 DANIEL MCCALL DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-7129
Practice Address - Country:US
Practice Address - Phone:936-639-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68543183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist