Healthcare Provider Details

I. General information

NPI: 1730045287
Provider Name (Legal Business Name): YI PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11120 S LAKES DR
RESTON VA
20191-4327
US

IV. Provider business mailing address

9710 CARDINAL RD
FAIRFAX VA
22030-1919
US

V. Phone/Fax

Practice location:
  • Phone: 703-853-9992
  • Fax:
Mailing address:
  • Phone: 703-853-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202223224
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: