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General NPI Number Information
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NPI Number | 1932412459
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Entity Type | Individual
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Provider Name | KYOUNG JIN PARK
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Gender | Male
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Dates
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Enumeration Date | 07/26/2010
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 1501 W MAIN ST
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City | EL CENTRO
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State | CA
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Zip | 92243-2211
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Country | US
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Telephone | 760-352-5731
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Fax |
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Provider Business Mailing Address
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Address Line | 3799 BLOSSOM WAY
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City | EL CENTRO
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State | CA
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Zip | 92243-8429
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Country | US
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Telephone | 760-554-2257
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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 | 64768
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License Number State | CA
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