Healthcare Provider Details

I. General information

NPI: 1275267270
Provider Name (Legal Business Name): KWON PARK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KWONNEUNG PARK

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 NORTHWAY DR STE 200
SAINT CLOUD MN
56303-4913
US

IV. Provider business mailing address

1555 NORTHWAY DR STE 200
SAINT CLOUD MN
56303-4913
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-3102
  • Fax:
Mailing address:
  • Phone: 320-240-3102
  • Fax: 320-240-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number125656
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number125656
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: