Provider Demographics
NPI:1457401986
Name:JEON, WAN SU (RPH)
Entity Type:Individual
Prefix:MR
First Name:WAN
Middle Name:SU
Last Name:JEON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 BOWDOIN ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6117
Mailing Address - Country:US
Mailing Address - Phone:718-983-6285
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM X BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist