Provider Demographics
NPI:1104137355
Name:PARK, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LEMOYNE
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1416
Mailing Address - Country:US
Mailing Address - Phone:717-737-3359
Mailing Address - Fax:
Practice Address - Street 1:108 ROUTE 44
Practice Address - Street 2:
Practice Address - City:MILLERTON
Practice Address - State:NY
Practice Address - Zip Code:12546-5237
Practice Address - Country:US
Practice Address - Phone:518-789-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2025-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP438640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist