Provider Demographics
NPI:1437928470
Name:SONG, JIMIN (RPH)
Entity type:Individual
Prefix:
First Name:JIMIN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HILLTOP DR APT 123
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-2820
Mailing Address - Country:US
Mailing Address - Phone:617-777-3817
Mailing Address - Fax:
Practice Address - Street 1:1070 E CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1114
Practice Address - Country:US
Practice Address - Phone:530-222-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH89138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist