Provider Demographics
NPI:1306223979
Name:PARK, JAYOUNG
Entity Type:Individual
Prefix:
First Name:JAYOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 BELL BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1640
Mailing Address - Country:US
Mailing Address - Phone:718-644-1555
Mailing Address - Fax:
Practice Address - Street 1:1612 BELL BLVD FL 2
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-1640
Practice Address - Country:US
Practice Address - Phone:718-644-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-02
Last Update Date:2015-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist