Provider Demographics
NPI:1700480142
Name:KANG, PAULINE EBUDE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:EBUDE
Last Name:KANG
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 E CHESTNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-3737
Mailing Address - Country:US
Mailing Address - Phone:302-368-3246
Mailing Address - Fax:
Practice Address - Street 1:366 E CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3737
Practice Address - Country:US
Practice Address - Phone:302-368-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0005336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEA1-0005336Medicaid