Provider Demographics
NPI:1831462803
Name:BAE, JUNG S
Entity Type:Individual
Prefix:MRS
First Name:JUNG
Middle Name:S
Last Name:BAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17643 SHERMAN WAY
Mailing Address - Street 2:#104
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3510
Mailing Address - Country:US
Mailing Address - Phone:818-708-0728
Mailing Address - Fax:818-708-1253
Practice Address - Street 1:17643 SHERMAN WAY
Practice Address - Street 2:#104
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3510
Practice Address - Country:US
Practice Address - Phone:818-708-0728
Practice Address - Fax:818-708-1253
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 44716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6113820001Medicare NSC