Provider Demographics
NPI:1396013595
Name:PARK, GIL JA
Entity Type:Individual
Prefix:
First Name:GIL
Middle Name:JA
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 1:7 HIGHFIELD GLN
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4042
Mailing Address - Country:US
Mailing Address - Phone:949-552-1178
Mailing Address - Fax:
Practice Address - Street 1:1330 E 17TH ST
Practice Address - Street 2:T-0286
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8500
Practice Address - Country:US
Practice Address - Phone:714-547-1042
Practice Address - Fax:714-547-1042
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist