Provider Demographics
NPI:1972881043
Name:KWON, MICHELLE M (RPH)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:KWON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2072 LYANS DR
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1537
Mailing Address - Country:US
Mailing Address - Phone:818-248-0408
Mailing Address - Fax:
Practice Address - Street 1:1075 N WESTERN AVE
Practice Address - Street 2:117
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2307
Practice Address - Country:US
Practice Address - Phone:323-465-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-23
Last Update Date:2011-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA313963OtherNABP