Healthcare Provider Details

I. General information

NPI: 1356204630
Provider Name (Legal Business Name): EDWIN PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 WHITE ROCK RD
RANCHO CORDOVA CA
95670-6010
US

IV. Provider business mailing address

3960 PENNSYLVANIA AVE UNIT 115
GLENDALE CA
91214-3788
US

V. Phone/Fax

Practice location:
  • Phone: 800-977-2273
  • Fax:
Mailing address:
  • Phone: 818-967-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number91651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: