Provider Demographics
NPI:1770839680
Name:MEN, SOPHORN (IR)
Entity Type:Individual
Prefix:MRS
First Name:SOPHORN
Middle Name:
Last Name:MEN
Suffix:
Gender:F
Credentials:IR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15533 WAYNITA WAY NE APT A301
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-7418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4727 DENVER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-2316
Practice Address - Country:US
Practice Address - Phone:206-763-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60026093183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician