Provider Demographics
NPI:1194125757
Name:PARK, JANE (PHARMD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 S VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6503
Mailing Address - Country:US
Mailing Address - Phone:805-665-5562
Mailing Address - Fax:805-665-5563
Practice Address - Street 1:1739 S VICTORIA AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6503
Practice Address - Country:US
Practice Address - Phone:805-665-5562
Practice Address - Fax:805-665-5563
Is Sole Proprietor?:No
Enumeration Date:2014-09-01
Last Update Date:2014-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist