MEDICARE: MR. JAE Y PARK RPH

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	PHY44525	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699750182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAE Y PARK RPH

Provider Business Mailing Address
First Line	:	3307 W PICO BL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-4530
Country	:	US
Telephone Number	:	323-734-1177
Fax Number	:	323-734-1178

Provider Business Practice Location Address
First Line	:	3307 W PICO BL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-4530
Country	:	US
Telephone Number	:	323-734-1177
Fax Number	:	323-734-1178

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	07/08/2007

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