Provider Demographics
NPI:1386739761
Name:ROH, CHONG WON
Entity type:Individual
Prefix:MRS
First Name:CHONG
Middle Name:WON
Last Name:ROH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10940 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3725
Mailing Address - Country:US
Mailing Address - Phone:818-763-4334
Mailing Address - Fax:818-763-4610
Practice Address - Street 1:10940 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3725
Practice Address - Country:US
Practice Address - Phone:818-763-4334
Practice Address - Fax:818-763-4610
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY44783183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA447830Medicaid
CAPHA447830Medicaid