Provider Demographics
NPI:1376826172
Name:SO, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:SO
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 1:185 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5522
Mailing Address - Country:US
Mailing Address - Phone:781-321-1765
Mailing Address - Fax:781-397-0017
Practice Address - Street 1:185 CENTRE ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5522
Practice Address - Country:US
Practice Address - Phone:781-321-1765
Practice Address - Fax:781-397-0017
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA27762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist