Provider Demographics
NPI:1982107223
Name:SHIN, ASHLEY JEESOO
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JEESOO
Last Name:SHIN
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 1:12035 FOSTER RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-8747
Mailing Address - Country:US
Mailing Address - Phone:714-388-2345
Mailing Address - Fax:
Practice Address - Street 1:5161 BEACH BLVD STE C
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-1171
Practice Address - Country:US
Practice Address - Phone:714-228-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist