Provider Demographics
NPI:1053539676
Name:YANG, KEUMJA
Entity type:Individual
Prefix:
First Name:KEUMJA
Middle Name:
Last Name:YANG
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 1:828 ADELITA ST
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2505
Mailing Address - Country:US
Mailing Address - Phone:323-725-6458
Mailing Address - Fax:323-278-1121
Practice Address - Street 1:3001 W BEVERLY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2255
Practice Address - Country:US
Practice Address - Phone:323-722-0778
Practice Address - Fax:323-278-1121
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist