Provider Demographics
NPI:1053942771
Name:KOO, BONJUN
Entity type:Individual
Prefix:
First Name:BONJUN
Middle Name:
Last Name:KOO
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 1:1910 OXLEY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3438
Mailing Address - Country:US
Mailing Address - Phone:213-800-2952
Mailing Address - Fax:
Practice Address - Street 1:1910 OXLEY ST
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3438
Practice Address - Country:US
Practice Address - Phone:213-800-2952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist