Provider Demographics
NPI:1194707562
Name:PARK, THOMAS S (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23357 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4957
Mailing Address - Country:US
Mailing Address - Phone:310-456-9059
Mailing Address - Fax:310-456-6529
Practice Address - Street 1:23357 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4957
Practice Address - Country:US
Practice Address - Phone:310-456-9059
Practice Address - Fax:310-456-6529
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH46855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist