Provider Demographics
NPI:1205906112
Name:SUNG, KI RO (R PH)
Entity type:Individual
Prefix:
First Name:KI RO
Middle Name:
Last Name:SUNG
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13673 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2433
Mailing Address - Country:US
Mailing Address - Phone:718-358-3800
Mailing Address - Fax:718-358-7615
Practice Address - Street 1:13673 41ST AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2433
Practice Address - Country:US
Practice Address - Phone:718-358-3800
Practice Address - Fax:718-358-7615
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00893370Medicaid
NY0758160001Medicare NSC
NY00893370Medicaid