Provider Demographics
NPI:1285888149
Name:PAK, MIKYONG
Entity type:Individual
Prefix:
First Name:MIKYONG
Middle Name:
Last Name:PAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKI
Other - Middle Name:
Other - Last Name:PAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15719 LABURNUM AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2660 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1836
Practice Address - Country:US
Practice Address - Phone:516-409-0907
Practice Address - Fax:516-409-9376
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist