Provider Demographics
NPI:1407103310
Name:PARK, PUP-SHIN (RPH)
Entity Type:Individual
Prefix:
First Name:PUP-SHIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 166TH CT SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6076
Mailing Address - Country:US
Mailing Address - Phone:206-355-1903
Mailing Address - Fax:253-839-1477
Practice Address - Street 1:31260 PACIFIC HWY S STE 10
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5448
Practice Address - Country:US
Practice Address - Phone:253-839-1399
Practice Address - Fax:253-839-1477
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00013062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist