Provider Demographics
NPI:1023566478
Name:PARK, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 ROUTE 36
Mailing Address - Street 2:
Mailing Address - City:PORT MONMOUTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07758-1359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 ROUTE 36
Practice Address - Street 2:
Practice Address - City:PORT MONMOUTH
Practice Address - State:NJ
Practice Address - Zip Code:07758-1359
Practice Address - Country:US
Practice Address - Phone:732-832-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03816000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist