Provider Demographics
NPI:1639686389
Name:SUH, HAE YOUNG
Entity Type:Individual
Prefix:
First Name:HAE
Middle Name:YOUNG
Last Name:SUH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HAE
Other - Middle Name:YOUNG
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11896 AMARGOSA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-8133
Mailing Address - Country:US
Mailing Address - Phone:760-951-5188
Mailing Address - Fax:
Practice Address - Street 1:11896 AMARGOSA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-8133
Practice Address - Country:US
Practice Address - Phone:760-951-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist