Provider Demographics
NPI:1508615352
Name:BAE, CHAEWON
Entity type:Individual
Prefix:
First Name:CHAEWON
Middle Name:
Last Name:BAE
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 1:25233 SHEPARDSON DR APT 4
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2925
Mailing Address - Country:US
Mailing Address - Phone:951-772-2641
Mailing Address - Fax:
Practice Address - Street 1:1040 S MOUNT VERNON AVE STE E
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4228
Practice Address - Country:US
Practice Address - Phone:909-222-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist