Provider Demographics
NPI:1154670032
Name:PARK, VIVIAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5423
Mailing Address - Country:US
Mailing Address - Phone:631-462-5463
Mailing Address - Fax:
Practice Address - Street 1:4 HENRY ST
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5423
Practice Address - Country:US
Practice Address - Phone:631-462-5463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist