Provider Demographics
NPI:1275009854
Name:SONG, SEUNG
Entity Type:Individual
Prefix:
First Name:SEUNG
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7719 PAIGE CT
Mailing Address - Street 2:
Mailing Address - City:WINTON
Mailing Address - State:CA
Mailing Address - Zip Code:95388-9440
Mailing Address - Country:US
Mailing Address - Phone:209-628-1414
Mailing Address - Fax:
Practice Address - Street 1:3055 LOUGHBOROUGH DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-1119
Practice Address - Country:US
Practice Address - Phone:209-384-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA79079OtherBOARD OF PHARMACY