Provider Demographics
NPI:1790008225
Name:NAM, KYONG (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KYONG
Middle Name:
Last Name:NAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4934
Mailing Address - Country:US
Mailing Address - Phone:917-887-5195
Mailing Address - Fax:718-886-5775
Practice Address - Street 1:4030 MURRAY ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4934
Practice Address - Country:US
Practice Address - Phone:917-887-5195
Practice Address - Fax:718-886-5775
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY043340OtherSTATE LICENSE