Provider Demographics
NPI:1194298257
Name:PARK, NATHANIEL JEONG SU
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:JEONG SU
Last Name:PARK
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 1:4201 JEWETTA AVE APT H10
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-5490
Mailing Address - Country:US
Mailing Address - Phone:213-284-2186
Mailing Address - Fax:
Practice Address - Street 1:100 CHINA GRADE LOOP
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-1739
Practice Address - Country:US
Practice Address - Phone:661-393-3358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH80055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist