Provider Demographics
NPI:1366819708
Name:PARK, MICHELLE ANNA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNA
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12254 BELLFLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12254 BELLFLOWER BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2804
Practice Address - Country:US
Practice Address - Phone:562-658-3874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist