Provider Demographics
NPI:1972938751
Name:SO, VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:SO
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 1:6030 MISSION TRL APT 5
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3551 CASSOPOLIS ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6743
Practice Address - Country:US
Practice Address - Phone:224-392-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025251A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist