Provider Demographics
NPI:1831314491
Name:KANG, BONGSEOK
Entity Type:Individual
Prefix:
First Name:BONGSEOK
Middle Name:
Last Name:KANG
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 1:2925 N KNIGHTSBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9292
Mailing Address - Country:US
Mailing Address - Phone:248-321-1476
Mailing Address - Fax:
Practice Address - Street 1:640 N MILFORD RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1534
Practice Address - Country:US
Practice Address - Phone:248-676-2916
Practice Address - Fax:248-676-9993
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist