Provider Demographics
NPI:1164015772
Name:BAN, MATTHEW DONG HUN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DONG HUN
Last Name:BAN
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 1:391 17TH ST NW UNIT 3012
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30363-1170
Mailing Address - Country:US
Mailing Address - Phone:419-344-4217
Mailing Address - Fax:
Practice Address - Street 1:1765 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5969
Practice Address - Country:US
Practice Address - Phone:770-914-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032663183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist