Provider Demographics
NPI:1730350455
Name:CHANG, YONG TAE (RPH)
Entity type:Individual
Prefix:
First Name:YONG
Middle Name:TAE
Last Name:CHANG
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 1:1 PATHMARK PLZ
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-3518
Mailing Address - Country:US
Mailing Address - Phone:914-668-5989
Mailing Address - Fax:914-668-6005
Practice Address - Street 1:1 PATHMARK PLZ
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3518
Practice Address - Country:US
Practice Address - Phone:914-668-5989
Practice Address - Fax:914-668-6005
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist