Provider Demographics
NPI:1336396084
Name:PAE, YON KYONG
Entity Type:Individual
Prefix:
First Name:YON KYONG
Middle Name:
Last Name:PAE
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 1:1301 S BEACH BLVD
Mailing Address - Street 2:STE K
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-1110
Mailing Address - Country:US
Mailing Address - Phone:562-947-8811
Mailing Address - Fax:562-947-8688
Practice Address - Street 1:1301 S BEACH BLVD
Practice Address - Street 2:STE K
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-1110
Practice Address - Country:US
Practice Address - Phone:562-947-8811
Practice Address - Fax:562-947-8688
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 51491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5575510001Medicare NSC