Provider Demographics
NPI:1225360654
Name:PARK, KI CHOL
Entity Type:Individual
Prefix:MR
First Name:KI CHOL
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 1:5601 BLVD EAST APT 23G
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3549
Mailing Address - Country:US
Mailing Address - Phone:201-868-4286
Mailing Address - Fax:
Practice Address - Street 1:2032 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-2802
Practice Address - Country:US
Practice Address - Phone:212-369-6075
Practice Address - Fax:212-369-4045
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist