Provider Demographics
NPI:1518695105
Name:SONG, JIN YOUNG
Entity Type:Individual
Prefix:
First Name:JIN YOUNG
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 1:2727 MERRILEE DR APT 522
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4456
Mailing Address - Country:US
Mailing Address - Phone:646-476-1310
Mailing Address - Fax:
Practice Address - Street 1:2601 RICHMOND HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-1057
Practice Address - Country:US
Practice Address - Phone:571-645-7309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist