Provider Demographics
NPI:1891019618
Name:CHANG, SUNG AE (RPH)
Entity Type:Individual
Prefix:MS
First Name:SUNG AE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CHESTERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-7883
Mailing Address - Country:US
Mailing Address - Phone:917-733-3299
Mailing Address - Fax:718-260-4812
Practice Address - Street 1:100 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-2005
Practice Address - Country:US
Practice Address - Phone:718-260-7653
Practice Address - Fax:718-260-4812
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist