MEDICARE: SOPHAKHONTERRY SON

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	RPH026800	GA

General Provider Information

NPI Number	:	1811433857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHAKHONTERRY SON

Provider Business Mailing Address
First Line	:	1817 DALLAS NEBO RD
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30134-4865
Country	:	US
Telephone Number	:	678-383-8715
Fax Number	:	678-383-8716

Provider Business Practice Location Address
First Line	:	1817 DALLAS NEBO RD
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30134-4865
Country	:	US
Telephone Number	:	678-383-8715
Fax Number	:	678-383-8716

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

Provider Enumeration Date	:	01/14/2017
Last Update Date	:	01/14/2017

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