Provider Demographics
NPI:1588963466
Name:MOON, SOOJIN VICTORIA (RPH)
Entity type:Individual
Prefix:MRS
First Name:SOOJIN
Middle Name:VICTORIA
Last Name:MOON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650
Mailing Address - Country:US
Mailing Address - Phone:347-756-0779
Mailing Address - Fax:
Practice Address - Street 1:119 BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650
Practice Address - Country:US
Practice Address - Phone:201-592-0735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03679700183500000X
NY054602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01612037Medicaid