Provider Demographics
NPI:1316344187
Name:PARK, JUDY
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 CREEK MANOR WAY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6564
Mailing Address - Country:US
Mailing Address - Phone:404-663-8875
Mailing Address - Fax:
Practice Address - Street 1:2020 HOWELL MILL RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-1732
Practice Address - Country:US
Practice Address - Phone:404-351-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-22
Last Update Date:2014-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028241183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist