Provider Demographics
NPI:1811417207
Name:UNG, PETHIDIN
Entity Type:Individual
Prefix:
First Name:PETHIDIN
Middle Name:
Last Name:UNG
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 1:175 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3708
Mailing Address - Country:US
Mailing Address - Phone:949-631-9223
Mailing Address - Fax:949-631-6907
Practice Address - Street 1:175 E 17TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3708
Practice Address - Country:US
Practice Address - Phone:949-631-9223
Practice Address - Fax:949-631-6907
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist