MEDICARE: RICKY SOU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	062649	NY

General Provider Information

NPI Number	:	1275079337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICKY SOU

Provider Business Mailing Address
First Line	:	3165 138TH ST APT 1A
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11354-2635
Country	:	US
Telephone Number	:	347-720-9260
Fax Number	:

Provider Business Practice Location Address
First Line	:	6352 108TH ST
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1350
Country	:	US
Telephone Number	:	917-832-6494
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2017
Last Update Date	:	03/17/2018

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Directions to “ RICKY SOU ” Practice Location

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