Provider Demographics
NPI:1841700457
Name:GWAG, CHUL HAK (PHARMD)
Entity type:Individual
Prefix:
First Name:CHUL HAK
Middle Name:
Last Name:GWAG
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 1:10124 QUEENS BLVD APT 4A
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2778
Mailing Address - Country:US
Mailing Address - Phone:909-993-7175
Mailing Address - Fax:
Practice Address - Street 1:14429 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4230
Practice Address - Country:US
Practice Address - Phone:718-886-6645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist