Provider Demographics
NPI:1962423939
Name:YONG W JEONG
Entity type:Organization
Organization Name:YONG W JEONG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH LAC PHD
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:JEONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-247-5670
Mailing Address - Street 1:2552 ROYAL LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-3417
Mailing Address - Country:US
Mailing Address - Phone:972-247-5670
Mailing Address - Fax:
Practice Address - Street 1:2552 ROYAL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-3417
Practice Address - Country:US
Practice Address - Phone:972-247-5670
Practice Address - Fax:972-247-5670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX115643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142912Medicaid
2096580OtherPK
2096580OtherPK