Provider Demographics
NPI:1831472646
Name:KANG, SOOYOUN
Entity Type:Individual
Prefix:
First Name:SOOYOUN
Middle Name:
Last Name:KANG
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 1:54 ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-3359
Mailing Address - Country:US
Mailing Address - Phone:978-921-0506
Mailing Address - Fax:
Practice Address - Street 1:54 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-3359
Practice Address - Country:US
Practice Address - Phone:978-921-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH26834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist