Provider Demographics
NPI:1205338407
Name:JI, TAE HYUNG (RPH)
Entity type:Individual
Prefix:
First Name:TAE HYUNG
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 HOWARD AVE APT D
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3748
Mailing Address - Country:US
Mailing Address - Phone:562-370-0443
Mailing Address - Fax:
Practice Address - Street 1:4222 HOWARD AVE APT D
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3748
Practice Address - Country:US
Practice Address - Phone:562-370-0443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist