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General NPI Number Information
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NPI Number | 1780938308
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Entity Type | Individual
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Provider Name | MIN GEON PARK PHARMACIST
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Gender | Male
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Dates
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Enumeration Date | 11/05/2012
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Last Update Date | 11/05/2012
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Provider Practice Location Address
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Address Line | 2420 WISTERIA DR
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City | SNELLVILLE
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State | GA
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Zip | 30078-6127
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Country | US
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Telephone | 770-972-1592
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Fax |
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Provider Business Mailing Address
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Address Line | 4761 BANKSIDE WAY
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City | NORCROSS
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State | GA
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Zip | 30092-5302
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Country | US
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Telephone | 770-242-8961
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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 | 019445
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License Number State | GA
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