Healthcare Provider Details

I. General information

NPI: 1821721887
Provider Name (Legal Business Name): JI PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HIGHLAND CORPORATE DR
CUMBERLAND RI
02864-8703
US

IV. Provider business mailing address

1505 MASSACHUSETTS AVE UNIT 11
LEXINGTON MA
02420-3842
US

V. Phone/Fax

Practice location:
  • Phone: 800-746-7287
  • Fax:
Mailing address:
  • Phone: 978-995-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH06269
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: