Provider Demographics
NPI:1497327555
Name:PARK, HARRISON
Entity Type:Individual
Prefix:
First Name:HARRISON
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 1:130 DESIARD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-998-3907
Mailing Address - Fax:
Practice Address - Street 1:130 DESIARD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7319
Practice Address - Country:US
Practice Address - Phone:318-998-3907
Practice Address - Fax:716-948-1932
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15843183500000X
LAPST.023939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist