Provider Demographics
NPI:1649594045
Name:SHIN, SONG (RPH, MS)
Entity Type:Individual
Prefix:MRS
First Name:SONG
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:RPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 TIOGA DR
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1930
Mailing Address - Country:US
Mailing Address - Phone:917-902-8510
Mailing Address - Fax:
Practice Address - Street 1:5904 KISSENA BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5546
Practice Address - Country:US
Practice Address - Phone:718-463-8018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028987-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist