Provider Demographics
NPI:1679016356
Name:SO, CHUNKIT
Entity Type:Individual
Prefix:
First Name:CHUNKIT
Middle Name:
Last Name:SO
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 1:5415 S KILDARE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5415 S KILDARE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4629
Practice Address - Country:US
Practice Address - Phone:773-971-8996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296016183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist