Provider Demographics
NPI:1750798633
Name:KWON, EDDIE
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W LA VETA AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4301
Mailing Address - Country:US
Mailing Address - Phone:949-215-5522
Mailing Address - Fax:
Practice Address - Street 1:27641 BOUQUET CANYON RD
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:CA
Practice Address - Zip Code:91350-1793
Practice Address - Country:US
Practice Address - Phone:661-296-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-12
Last Update Date:2014-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist