Provider Demographics
NPI:1255843827
Name:SHIN, SOO JIN
Entity Type:Individual
Prefix:MS
First Name:SOO JIN
Middle Name:
Last Name:SHIN
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 1:2470 MONTROSE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1474
Mailing Address - Country:US
Mailing Address - Phone:818-439-7526
Mailing Address - Fax:
Practice Address - Street 1:19353 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91335-6302
Practice Address - Country:US
Practice Address - Phone:818-996-4742
Practice Address - Fax:818-996-0782
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty