Healthcare Provider Details

I. General information

NPI: 1013676873
Provider Name (Legal Business Name): DAE KYONG SONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 SUNSET LAKE RD
APEX NC
27539-8792
US

IV. Provider business mailing address

5153 SUNSET LAKE RD
APEX NC
27539-8792
US

V. Phone/Fax

Practice location:
  • Phone: 919-290-2630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number30777
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: