Provider Demographics
NPI:1417494931
Name:PARK, CHANGMIN
Entity Type:Individual
Prefix:
First Name:CHANGMIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CALLAWAY DR
Mailing Address - Street 2:APT 603
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 S CANAL ST
Practice Address - Street 2:PHARMACY
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-6523
Practice Address - Country:US
Practice Address - Phone:575-885-1029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist