Provider Demographics
NPI:1245831080
Name:SIM, CHAEHOON
Entity type:Individual
Prefix:
First Name:CHAEHOON
Middle Name:
Last Name:SIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 JOHN MILTON DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2527
Mailing Address - Country:US
Mailing Address - Phone:703-620-9664
Mailing Address - Fax:
Practice Address - Street 1:2551 JOHN MILTON DR
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-2527
Practice Address - Country:US
Practice Address - Phone:703-620-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist