Provider Demographics
NPI:1356605547
Name:JEONG, YONG W (LAC)
Entity type:Individual
Prefix:
First Name:YONG
Middle Name:W
Last Name:JEONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2552 ROYAL LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-3417
Mailing Address - Country:US
Mailing Address - Phone:972-247-5670
Mailing Address - Fax:
Practice Address - Street 1:2552 ROYAL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-3417
Practice Address - Country:US
Practice Address - Phone:972-247-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist