Healthcare Provider Details

I. General information

NPI: 1528336039
Provider Name (Legal Business Name): MICHELLE PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22930 S WESTERN AVE
TORRANCE CA
90501-5112
US

IV. Provider business mailing address

22930 S WESTERN AVE
TORRANCE CA
90501-5112
US

V. Phone/Fax

Practice location:
  • Phone: 310-517-1851
  • Fax: 310-517-0368
Mailing address:
  • Phone: 310-517-1851
  • Fax: 310-517-0368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberA52127
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: