Provider Demographics
NPI:1619246105
Name:SONG, CHAEHOON
Entity Type:Individual
Prefix:MR
First Name:CHAEHOON
Middle Name:
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 1:301 W HOBSON WAY
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1639
Mailing Address - Country:US
Mailing Address - Phone:760-922-3511
Mailing Address - Fax:760-922-4404
Practice Address - Street 1:301 W HOBSON WAY
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1639
Practice Address - Country:US
Practice Address - Phone:760-922-3511
Practice Address - Fax:760-922-4404
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH61031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist