Provider Demographics
NPI:1316553894
Name:SU, JONAH
Entity Type:Individual
Prefix:
First Name:JONAH
Middle Name:
Last Name:SU
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 1:1433 N HOLLENBECK AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1558
Mailing Address - Country:US
Mailing Address - Phone:626-251-1640
Mailing Address - Fax:
Practice Address - Street 1:1433 N HOLLENBECK AVE STE 103
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1558
Practice Address - Country:US
Practice Address - Phone:626-251-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-19
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist