Provider Demographics
NPI:1407038433
Name:PARK, KAREN (RPH)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2031
Mailing Address - Country:US
Mailing Address - Phone:516-490-5595
Mailing Address - Fax:516-490-5594
Practice Address - Street 1:336 N BROADWAY
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2031
Practice Address - Country:US
Practice Address - Phone:516-490-5595
Practice Address - Fax:516-490-5594
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01804237Medicaid