Provider Demographics
NPI:1538692462
Name:PROBENE Q, LLC
Entity type:Organization
Organization Name:PROBENE Q, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WON KYU
Authorized Official - Middle Name:
Authorized Official - Last Name:SHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-916-4899
Mailing Address - Street 1:105 CHALLENGER RD STE 401
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07660-2101
Mailing Address - Country:US
Mailing Address - Phone:201-225-0057
Mailing Address - Fax:201-225-0067
Practice Address - Street 1:105 CHALLENGER RD STE 401
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07660-2101
Practice Address - Country:US
Practice Address - Phone:201-225-0057
Practice Address - Fax:201-225-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007553003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0573035Medicaid
2168729OtherPK