Provider Demographics
NPI:1407178692
Name:SONG, BO (PHARM D)
Entity Type:Individual
Prefix:MISS
First Name:BO
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24046 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24046 65TH AVE
Practice Address - Street 2:
Practice Address - City:DOUGLASTON
Practice Address - State:NY
Practice Address - Zip Code:11362-1921
Practice Address - Country:US
Practice Address - Phone:646-750-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist