MEDICARE: MRS. GRACE EUNJOO SEO RPH

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	051432	NY

General Provider Information

NPI Number	:	1679707657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACE EUNJOO SEO RPH

Provider Business Mailing Address
First Line	:	820 FORT SALONGA RD
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-3151
Country	:	US
Telephone Number	:	631-261-1057
Fax Number	:	631-754-0285

Provider Business Practice Location Address
First Line	:	820 FORT SALONGA RD
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-3151
Country	:	US
Telephone Number	:	631-261-1057
Fax Number	:	631-754-0285

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

Provider Enumeration Date	:	05/06/2009
Last Update Date	:	05/06/2009

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