Provider Demographics
NPI:1639985484
Name:AN, SUNGJOON DAVID (PHARMD)
Entity type:Individual
Prefix:
First Name:SUNGJOON
Middle Name:DAVID
Last Name:AN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 N GIRASOLO AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3391
Mailing Address - Country:US
Mailing Address - Phone:208-813-0414
Mailing Address - Fax:
Practice Address - Street 1:4657 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7077
Practice Address - Country:US
Practice Address - Phone:208-272-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID7071442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist