Provider Demographics
NPI:1508198219
Name:KONG, JIHYUN
Entity Type:Individual
Prefix:
First Name:JIHYUN
Middle Name:
Last Name:KONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20823 15TH RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1117
Mailing Address - Country:US
Mailing Address - Phone:917-660-1017
Mailing Address - Fax:
Practice Address - Street 1:16004 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-6110
Practice Address - Country:US
Practice Address - Phone:718-558-3987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist