Provider Demographics
NPI:1548858004
Name:SO, WAN
Entity type:Individual
Prefix:
First Name:WAN
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 1:1214 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-4404
Mailing Address - Country:US
Mailing Address - Phone:215-606-8291
Mailing Address - Fax:
Practice Address - Street 1:24 S BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:MOUNT EPHRAIM
Practice Address - State:NJ
Practice Address - Zip Code:08059-1321
Practice Address - Country:US
Practice Address - Phone:215-606-8291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP451430183500000X
NJ28RI03481900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist