Provider Demographics
NPI:1306164595
Name:JEON, WANSOO
Entity type:Individual
Prefix:
First Name:WANSOO
Middle Name:
Last Name:JEON
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 1:1800 STATE ST APT 40
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2125
Mailing Address - Country:US
Mailing Address - Phone:323-295-9661
Mailing Address - Fax:323-295-9596
Practice Address - Street 1:3230 W SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2564
Practice Address - Country:US
Practice Address - Phone:323-295-9661
Practice Address - Fax:323-295-9596
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH60864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist