Provider Demographics
NPI:1275267270
Name:PARK, KWON (PHARMD)
Entity Type:Individual
Prefix:
First Name:KWON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:KWONNEUNG
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1555 NORTHWAY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4913
Mailing Address - Country:US
Mailing Address - Phone:320-240-3102
Mailing Address - Fax:320-240-3164
Practice Address - Street 1:1555 NORTHWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4913
Practice Address - Country:US
Practice Address - Phone:320-240-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1256561835P2201X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care