Provider Demographics
NPI:1245894302
Name:SEO, JUSTIN SANG (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:SANG
Last Name:SEO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 W CHESTNUT AVE # A
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3251
Mailing Address - Country:US
Mailing Address - Phone:808-256-7261
Mailing Address - Fax:
Practice Address - Street 1:2519 MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION GAP
Practice Address - State:WA
Practice Address - Zip Code:98903-1605
Practice Address - Country:US
Practice Address - Phone:509-453-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60886076183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist