Provider Demographics
NPI:1467037325
Name:SONG, JIN KYUNG (RPH)
Entity Type:Individual
Prefix:
First Name:JIN KYUNG
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 CONSHOHOCKEN AVE APT 427
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-5345
Mailing Address - Country:US
Mailing Address - Phone:631-965-1331
Mailing Address - Fax:
Practice Address - Street 1:2727 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-2930
Practice Address - Country:US
Practice Address - Phone:215-886-7399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0015635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist