Provider Demographics
NPI:1174763510
Name:CHANG, KYUNG SOOK
Entity type:Individual
Prefix:MS
First Name:KYUNG
Middle Name:SOOK
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:K
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3700 DEAN DR UNIT 1008
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3272
Mailing Address - Country:US
Mailing Address - Phone:805-654-0728
Mailing Address - Fax:
Practice Address - Street 1:3700 DEAN DR UNIT 1008
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3272
Practice Address - Country:US
Practice Address - Phone:805-654-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist