Provider Demographics
NPI:1972140846
Name:SUON, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SUON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 ESTEP DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2614
Mailing Address - Country:US
Mailing Address - Phone:209-531-4903
Mailing Address - Fax:
Practice Address - Street 1:1779 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-5130
Practice Address - Country:US
Practice Address - Phone:209-825-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty