Provider Demographics
NPI:1962007815
Name:CHUNG, CHAE HYUNG
Entity Type:Individual
Prefix:
First Name:CHAE
Middle Name:HYUNG
Last Name:CHUNG
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 1:411 WILLOW WINDS PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7271
Mailing Address - Country:US
Mailing Address - Phone:770-596-9919
Mailing Address - Fax:
Practice Address - Street 1:152 FRONT ST
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3058
Practice Address - Country:US
Practice Address - Phone:904-285-3634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist