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General NPI Number Information
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NPI Number | 1679397012
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Entity Type | Individual
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Provider Name | JAEHONG PARK
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Gender | Male
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Dates
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Enumeration Date | 11/12/2024
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 2129 E BELT LINE RD
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City | RICHARDSON
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State | TX
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Zip | 75081-3931
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Country | US
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Telephone | 972-235-8417
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Fax |
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Provider Business Mailing Address
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Address Line | 520 SMOKE TREE DR
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City | MURPHY
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State | TX
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Zip | 75094-5335
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Country | US
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Telephone | 346-387-1196
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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 | 75059
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License Number State | TX
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