Provider Demographics
NPI:1548797962
Name:AHN, JAE
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2723
Mailing Address - Country:US
Mailing Address - Phone:201-751-4984
Mailing Address - Fax:201-751-4985
Practice Address - Street 1:4505 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-2723
Practice Address - Country:US
Practice Address - Phone:201-751-4984
Practice Address - Fax:201-751-4985
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS007559003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RS00755900OtherPHARMACY PERMIT NUMBER