Provider Demographics
NPI:1679707657
Name:SEO, GRACE EUNJOO (RPH)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:EUNJOO
Last Name:SEO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 FORT SALONGA RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3151
Mailing Address - Country:US
Mailing Address - Phone:631-261-1057
Mailing Address - Fax:631-754-0285
Practice Address - Street 1:820 FORT SALONGA RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3151
Practice Address - Country:US
Practice Address - Phone:631-261-1057
Practice Address - Fax:631-754-0285
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist