Healthcare Provider Details

I. General information

NPI: 1528981040
Provider Name (Legal Business Name): JUNGIN PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E BRISTOL ST
ELKHART IN
46514-3624
US

IV. Provider business mailing address

520 UNIVERSITY PARK CT APT D
MISHAWAKA IN
46545-1278
US

V. Phone/Fax

Practice location:
  • Phone: 574-206-8476
  • Fax:
Mailing address:
  • Phone: 765-701-9214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26032151A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: