Provider Demographics
NPI:1952774317
Name:SON, SUNG JA
Entity Type:Individual
Prefix:
First Name:SUNG JA
Middle Name:
Last Name:SON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2522
Practice Address - Country:US
Practice Address - Phone:650-364-2111
Practice Address - Fax:650-364-4131
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-07
Last Update Date:2015-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist