Provider Demographics
NPI:1649385022
Name:SONG, KELLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLEY
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 1:1339 W GARVEY AVE N
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2242
Mailing Address - Country:US
Mailing Address - Phone:626-814-0111
Mailing Address - Fax:888-216-2114
Practice Address - Street 1:1339 W GARVEY AVE N
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2242
Practice Address - Country:US
Practice Address - Phone:626-814-0111
Practice Address - Fax:888-216-2114
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist