Provider Demographics
NPI:1679659726
Name:DOUGIE FRESH INC
Entity Type:Organization
Organization Name:DOUGIE FRESH INC
Other - Org Name:HAEUN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEOG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-635-6532
Mailing Address - Street 1:7300 OLD YORK RD
Mailing Address - Street 2:STE 210
Mailing Address - City:MELROSE PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3037
Mailing Address - Country:US
Mailing Address - Phone:215-635-6532
Mailing Address - Fax:215-635-2745
Practice Address - Street 1:7300 OLD YORK RD
Practice Address - Street 2:STE 210
Practice Address - City:MELROSE PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-3037
Practice Address - Country:US
Practice Address - Phone:215-635-6532
Practice Address - Fax:215-635-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4812833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027895800001Medicaid
2138837OtherPK