Provider Demographics
NPI:1548423593
Name:PARK, ELISA (PHARM D)
Entity Type:Individual
Prefix:
First Name:ELISA
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 1:200 MUIR RD
Mailing Address - Street 2:HACIENDA BLDG RM H1B18
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MUIR RD
Practice Address - Street 2:HACIENDA BLDG RM H1B18
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4614
Practice Address - Country:US
Practice Address - Phone:925-229-7660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist