Provider Demographics
NPI:1881040863
Name:BUNGA TERATAI CEMERIANG AMERICA INC
Entity Type:Organization
Organization Name:BUNGA TERATAI CEMERIANG AMERICA INC
Other - Org Name:KEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUKEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-579-0719
Mailing Address - Street 1:583 E FOOTHILL BLVD
Mailing Address - Street 2:UNITS 7 & 8
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3995
Mailing Address - Country:US
Mailing Address - Phone:909-579-0719
Mailing Address - Fax:909-579-0721
Practice Address - Street 1:583 E FOOTHILL BLVD
Practice Address - Street 2:UNITS 7 AND 8
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3995
Practice Address - Country:US
Practice Address - Phone:909-579-0719
Practice Address - Fax:909-579-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY543913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1881040863Medicaid
2160375OtherPK