Provider Demographics
NPI:1407211261
Name:PAK, SONG (RPH)
Entity Type:Individual
Prefix:MR
First Name:SONG
Middle Name:
Last Name:PAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MONTAIGNE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4307
Mailing Address - Country:US
Mailing Address - Phone:210-316-1140
Mailing Address - Fax:
Practice Address - Street 1:6520 FRATT RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-4402
Practice Address - Country:US
Practice Address - Phone:210-938-4536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist