Healthcare Provider Details

I. General information

NPI: 1699053587
Provider Name (Legal Business Name): MR. CHONGWOOK SONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 LASKIN RD
VIRGINIA BEACH VA
23451-6138
US

IV. Provider business mailing address

1661 LASKIN RD
VIRGINIA BEACH VA
23451-6138
US

V. Phone/Fax

Practice location:
  • Phone: 757-425-7665
  • Fax: 757-437-1605
Mailing address:
  • Phone: 757-425-7665
  • Fax: 757-437-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202012355
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: