Provider Demographics
NPI:1033950878
Name:JEONG, DAGAM (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DAGAM
Middle Name:
Last Name:JEONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COUNTRY SIDE LN APT 202
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2566
Mailing Address - Country:US
Mailing Address - Phone:617-650-5915
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:ANNEX BUILDING #416
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-606-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist