Provider Demographics
NPI:1710573704
Name:SONG, JONNAH
Entity Type:Individual
Prefix:
First Name:JONNAH
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 1:13025 DAHLIA CIR APT 314
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8015 DEN RD
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-4537
Practice Address - Country:US
Practice Address - Phone:952-941-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist