Provider Demographics
NPI:1508500943
Name:CHUNG, ANDRIENNE ALLYSON
Entity Type:Individual
Prefix:
First Name:ANDRIENNE
Middle Name:ALLYSON
Last Name:CHUNG
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 1:9486 AEGEAN DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-6683
Mailing Address - Country:US
Mailing Address - Phone:561-702-0205
Mailing Address - Fax:
Practice Address - Street 1:2955 W CORPORATE LAKES BLVD STE 600
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3663
Practice Address - Country:US
Practice Address - Phone:954-660-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist