Provider Demographics
NPI:1275858672
Name:PARK, JUN
Entity Type:Individual
Prefix:
First Name:JUN
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 1:5303 E CORTLAND BLVD
Mailing Address - Street 2:APT # R6
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-9564
Mailing Address - Country:US
Mailing Address - Phone:615-587-3416
Mailing Address - Fax:
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:615-587-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist