Provider Demographics
NPI:1467238527
Name:PARK, STEPHANIE (PHARM D)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12683 HERON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6636
Mailing Address - Country:US
Mailing Address - Phone:703-577-1302
Mailing Address - Fax:
Practice Address - Street 1:43930 FARMWELL HUNT PLZ
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5896
Practice Address - Country:US
Practice Address - Phone:703-724-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty