Provider Demographics
NPI:1518179886
Name:PARK, DAVID N (DPH)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:N
Last Name:PARK
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 LEIGHS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-6556
Mailing Address - Country:US
Mailing Address - Phone:901-483-6179
Mailing Address - Fax:
Practice Address - Street 1:290 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-1737
Practice Address - Country:US
Practice Address - Phone:901-483-6179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC4849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4420852Medicaid
TN4420852Medicaid