Provider Demographics
NPI:1710361399
Name:SONG, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 OAKLEDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-4903
Mailing Address - Country:US
Mailing Address - Phone:646-300-4868
Mailing Address - Fax:
Practice Address - Street 1:779 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-1615
Practice Address - Country:US
Practice Address - Phone:203-822-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY.00017513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7309630001Medicare NSC