Provider Demographics
NPI:1942586409
Name:SO, MYRENE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MYRENE
Middle Name:
Last Name:SO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3752 MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054
Mailing Address - Country:US
Mailing Address - Phone:760-722-9409
Mailing Address - Fax:
Practice Address - Street 1:3752 MISSION AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054
Practice Address - Country:US
Practice Address - Phone:760-722-9409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH64600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist