Provider Demographics
NPI:1972154045
Name:SON, WON-JAE
Entity type:Individual
Prefix:
First Name:WON-JAE
Middle Name:
Last Name:SON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 BILLINGS ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-1904
Mailing Address - Country:US
Mailing Address - Phone:860-794-3531
Mailing Address - Fax:
Practice Address - Street 1:214 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-4619
Practice Address - Country:US
Practice Address - Phone:617-277-6080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH609548693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy