Provider Demographics
NPI:1255563912
Name:JEONG, JAEHEE (RPH)
Entity type:Individual
Prefix:
First Name:JAEHEE
Middle Name:
Last Name:JEONG
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 1:27 ORINDA WAY
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-2538
Mailing Address - Country:US
Mailing Address - Phone:925-253-1904
Mailing Address - Fax:925-253-0925
Practice Address - Street 1:27 ORINDA WAY
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-2538
Practice Address - Country:US
Practice Address - Phone:925-253-1904
Practice Address - Fax:925-253-0925
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57015183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicare UPIN