Provider Demographics
NPI:1639452998
Name:JOSE, SONI K
Entity Type:Individual
Prefix:MR
First Name:SONI
Middle Name:K
Last Name:JOSE
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 1:2008 ALCOVY SHOALS BLF
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-2788
Mailing Address - Country:US
Mailing Address - Phone:678-407-0418
Mailing Address - Fax:
Practice Address - Street 1:2075 GRAYSON HWY
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1242
Practice Address - Country:US
Practice Address - Phone:770-338-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist