Provider Demographics
NPI:1033808092
Name:CHA, SOOYEON
Entity Type:Individual
Prefix:
First Name:SOOYEON
Middle Name:
Last Name:CHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 WATERVIEW DR UNIT 426
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-6368
Mailing Address - Country:US
Mailing Address - Phone:774-262-3880
Mailing Address - Fax:
Practice Address - Street 1:709 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2235
Practice Address - Country:US
Practice Address - Phone:847-662-8091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist