Provider Demographics
NPI:1376248674
Name:PARK, MINKYOUNG
Entity Type:Individual
Prefix:
First Name:MINKYOUNG
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 1:145 FRONT ST UNIT 1207
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1450
Mailing Address - Country:US
Mailing Address - Phone:240-665-8783
Mailing Address - Fax:
Practice Address - Street 1:595 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-3007
Practice Address - Country:US
Practice Address - Phone:781-828-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist