Provider Demographics
NPI:1760582571
Name:SONG, JAE HAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAE
Middle Name:HAN
Last Name:SONG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 LUDLOW ST
Mailing Address - Street 2:TRINITY DRUG INC
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705-1947
Mailing Address - Country:US
Mailing Address - Phone:914-965-5275
Mailing Address - Fax:914-965-2380
Practice Address - Street 1:45 LUDLOW ST
Practice Address - Street 2:TRINITY DRUG INC
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705-1947
Practice Address - Country:US
Practice Address - Phone:914-965-5275
Practice Address - Fax:914-965-2380
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist