Provider Demographics
NPI:1255642203
Name:JONG, SUKEN
Entity type:Individual
Prefix:MR
First Name:SUKEN
Middle Name:
Last Name:JONG
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 1:7339 MILLIKEN AVE
Mailing Address - Street 2:#110
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7442
Mailing Address - Country:US
Mailing Address - Phone:909-944-3543
Mailing Address - Fax:909-944-3823
Practice Address - Street 1:7339 MILLIKEN AVE
Practice Address - Street 2:#110
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7442
Practice Address - Country:US
Practice Address - Phone:909-944-3543
Practice Address - Fax:909-944-3823
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH42549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist