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General NPI Number Information
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NPI Number | 1619258100
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Entity Type | Individual
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Provider Name | JOHN BANSUK PARK PHARM.D.
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Gender | Male
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Dates
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Enumeration Date | 08/29/2011
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Last Update Date | 08/29/2011
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Provider Practice Location Address
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Address Line | 20200 BLOOMFIELD AVE
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City | CERRITOS
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State | CA
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Zip | 90703-7821
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Country | US
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Telephone | 562-274-0062
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Fax |
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Provider Business Mailing Address
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Address Line | 2205 W BROADWAY APT A219
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City | ANAHEIM
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State | CA
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Zip | 92804-2385
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Country | US
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Telephone | 858-344-4142
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 65907
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License Number State | CA
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