Healthcare Provider Details

I. General information

NPI: 1154244929
Provider Name (Legal Business Name): ADVANCED PARK WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 RIDGEFAIR DR
CUMMING GA
30040-1555
US

IV. Provider business mailing address

3450 RIDGEFAIR DR
CUMMING GA
30040-1555
US

V. Phone/Fax

Practice location:
  • Phone: 415-328-9083
  • Fax:
Mailing address:
  • Phone: 415-328-9083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHIN PARK
Title or Position: MANAGER
Credential:
Phone: 415-328-9083