Provider Demographics
NPI:1437556883
Name:SON, SEUNG WOO
Entity Type:Individual
Prefix:
First Name:SEUNG WOO
Middle Name:
Last Name:SON
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 1:4160 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2050
Mailing Address - Country:US
Mailing Address - Phone:318-742-4414
Mailing Address - Fax:318-742-0410
Practice Address - Street 1:4160 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2050
Practice Address - Country:US
Practice Address - Phone:318-742-4414
Practice Address - Fax:318-742-0410
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.020750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist