Healthcare Provider Details

I. General information

NPI: 1386318111
Provider Name (Legal Business Name): EDWARD TAE PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 VALLEY AVE E
SUMNER WA
98390-3225
US

IV. Provider business mailing address

5505 24TH ST NE
TACOMA WA
98422-3347
US

V. Phone/Fax

Practice location:
  • Phone: 253-826-8433
  • Fax: 253-826-8427
Mailing address:
  • Phone: 253-269-8722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH61180651
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: