Provider Demographics
NPI:1528382280
Name:KWON, HEASOOK
Entity Type:Individual
Prefix:
First Name:HEASOOK
Middle Name:
Last Name:KWON
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 1:1831 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-6323
Mailing Address - Country:US
Mailing Address - Phone:718-466-1000
Mailing Address - Fax:718-466-1006
Practice Address - Street 1:1831 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-6323
Practice Address - Country:US
Practice Address - Phone:718-466-1000
Practice Address - Fax:718-466-1006
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist