MEDICARE: SUSAN S PARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	14864	CO

General Provider Information

NPI Number	:	1598117012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN S PARK

Provider Business Mailing Address
First Line	:	15131 E CRESTLINE AVE
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80015-2517
Country	:	US
Telephone Number	:	720-289-2021
Fax Number	:

Provider Business Practice Location Address
First Line	:	15131 E CRESTLINE AVE
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80015-2517
Country	:	US
Telephone Number	:	720-289-2021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2016
Last Update Date	:	07/08/2016

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Directions to “ SUSAN S PARK ” Practice Location

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