Provider Demographics
NPI:1386318111
Name:PARK, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
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 1:1417 SW 351ST ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-6943
Mailing Address - Country:US
Mailing Address - Phone:253-269-8722
Mailing Address - Fax:
Practice Address - Street 1:33702 21ST AVE SW
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-7762
Practice Address - Country:US
Practice Address - Phone:253-952-0133
Practice Address - Fax:253-952-0142
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61180651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist