Provider Demographics
NPI:1114246501
Name:PARK, HAEWON ELIZABETH
Entity Type:Individual
Prefix:
First Name:HAEWON
Middle Name:ELIZABETH
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 VANDERVEER DR
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-3746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:531 US HIGHWAY 22 E
Practice Address - Street 2:
Practice Address - City:WHITEHOUSE STATION
Practice Address - State:NJ
Practice Address - Zip Code:08889-3695
Practice Address - Country:US
Practice Address - Phone:908-534-0019
Practice Address - Fax:908-534-1124
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02518300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist