Provider Demographics
NPI:1366578569
Name:QUON, SHUN
Entity type:Individual
Prefix:
First Name:SHUN
Middle Name:
Last Name:QUON
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 1:2039 FOREST AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2039 FOREST AVE
Practice Address - Street 2:STE 202
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4817
Practice Address - Country:US
Practice Address - Phone:408-295-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH38547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY309550Medicaid