Provider Demographics
NPI:1639405467
Name:SONG, TINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 WASHINGTON BLVD
Mailing Address - Street 2:PHARMACY
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1006
Mailing Address - Country:US
Mailing Address - Phone:562-698-0811
Mailing Address - Fax:
Practice Address - Street 1:12401 WASHINGTON BLVD
Practice Address - Street 2:PHARMACY
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1006
Practice Address - Country:US
Practice Address - Phone:562-698-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62996183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist