Healthcare Provider Details

I. General information

NPI: 1467923086
Provider Name (Legal Business Name): EUN YOUNG PARK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLIE PARK

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 E ST HWY 100
PALM COAST FL
32164-2365
US

IV. Provider business mailing address

1820 LEGENDS LN APT 5205
DAYTONA BEACH FL
32114-0010
US

V. Phone/Fax

Practice location:
  • Phone: 386-313-3952
  • Fax:
Mailing address:
  • Phone: 703-625-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202217211
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS63923
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: