Provider Demographics
NPI:1215488465
Name:PARK, JAE
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
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 1:9202 COMMERCIAL CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19933-3822
Mailing Address - Country:US
Mailing Address - Phone:302-337-9785
Mailing Address - Fax:
Practice Address - Street 1:9202 COMMERCIAL CENTRE DR
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:DE
Practice Address - Zip Code:19933-3822
Practice Address - Country:US
Practice Address - Phone:302-337-9785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist