Provider Demographics
NPI:1497110225
Name:SONG, JIN
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-7032
Mailing Address - Country:US
Mailing Address - Phone:909-981-0717
Mailing Address - Fax:
Practice Address - Street 1:311 S MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-7032
Practice Address - Country:US
Practice Address - Phone:909-981-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 67613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist