Provider Demographics
NPI:1275746240
Name:PARK, TYRUS (RPH)
Entity Type:Individual
Prefix:
First Name:TYRUS
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 N CIVIC DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596
Mailing Address - Country:US
Mailing Address - Phone:925-210-6659
Mailing Address - Fax:925-210-6606
Practice Address - Street 1:94-780A MEHEULA PKWY
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789
Practice Address - Country:US
Practice Address - Phone:808-623-6636
Practice Address - Fax:808-625-3894
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist