Provider Demographics
NPI:1538689237
Name:KWON, DAE (PHARMD RPH)
Entity Type:Individual
Prefix:
First Name:DAE
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:PHARMD RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-5102
Mailing Address - Country:US
Mailing Address - Phone:917-881-5947
Mailing Address - Fax:
Practice Address - Street 1:995 ROUTE 22
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-1526
Practice Address - Country:US
Practice Address - Phone:845-940-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0650411835P0018X
CTPCT.00137681835P0018X
NJ28RI040798001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist