Provider Demographics
NPI:1275079337
Name:SOU, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:SOU
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 1:3165 138TH ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-2635
Mailing Address - Country:US
Mailing Address - Phone:347-720-9260
Mailing Address - Fax:
Practice Address - Street 1:6352 108TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1350
Practice Address - Country:US
Practice Address - Phone:917-832-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062649183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist