Provider Demographics
NPI:1699750182
Name:PARK, JAE Y (RPH)
Entity type:Individual
Prefix:MR
First Name:JAE
Middle Name:Y
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 1:3307 W PICO BL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-4530
Mailing Address - Country:US
Mailing Address - Phone:323-734-1177
Mailing Address - Fax:323-734-1178
Practice Address - Street 1:3307 W PICO BL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-4530
Practice Address - Country:US
Practice Address - Phone:323-734-1177
Practice Address - Fax:323-734-1178
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY44525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA 445250Medicaid
CAPHA 445250Medicaid
0553912Medicare UPIN