Healthcare Provider Details

I. General information

NPI: 1679059257
Provider Name (Legal Business Name): DARA SUON PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4555 N PERSHING AVE STE 7
STOCKTON CA
95207-6739
US

IV. Provider business mailing address

13260 ALTA MESA RD
GALT CA
95632-8356
US

V. Phone/Fax

Practice location:
  • Phone: 209-373-9629
  • Fax: 209-473-7377
Mailing address:
  • Phone: 209-822-6311
  • Fax: 209-473-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: