Provider Demographics
NPI:1437283512
Name:SONG, IN POM
Entity Type:Individual
Prefix:MR
First Name:IN
Middle Name:POM
Last Name:SONG
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 1:4116 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-2998
Mailing Address - Country:US
Mailing Address - Phone:718-204-1414
Mailing Address - Fax:718-204-1413
Practice Address - Street 1:4116 30TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-2998
Practice Address - Country:US
Practice Address - Phone:718-204-1414
Practice Address - Fax:718-204-1413
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046758-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist