Active NPI
Eun Joo Song
- Pharmacist
- Kenosha, WI
National Provider Identifier
1801494380
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 17834-40
- Practice address
- 3500 Brumback Blvd
Kenosha, WI 53144-4816 - Phone
- (773) 502-1004
- NPI assigned
- Oct 15, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 17834-40 | WI | Primary |
Addresses
Primary practice location
3500 Brumback Blvd
Kenosha, WI 53144-4816
Mailing address
3500 Brumback Blvd
Kenosha, WI 53144-4816
Phone (262) 652-1458
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 17834-40 | WI | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1602720000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1602720000000",
"number": "1801494380",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3500 BRUMBACK BLVD",
"city": "KENOSHA",
"state": "WI",
"postal_code": "531444816",
"telephone_number": "262-652-1458"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3500 BRUMBACK BLVD",
"city": "KENOSHA",
"state": "WI",
"postal_code": "531444816",
"telephone_number": "773-502-1004"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SONG",
"first_name": "EUN JOO",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-10-15",
"last_updated": "2020-10-15",
"certification_date": "2020-10-15",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "WI",
"license": "17834-40",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Kenosha, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.