Provider Demographics
NPI:1104385467
Name:PARK, JIN WON
Entity Type:Individual
Prefix:
First Name:JIN WON
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 1:667 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4067
Mailing Address - Country:US
Mailing Address - Phone:301-317-3838
Mailing Address - Fax:
Practice Address - Street 1:667 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4067
Practice Address - Country:US
Practice Address - Phone:301-317-3838
Practice Address - Fax:301-317-3637
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist