Provider Demographics
NPI:1558085316
Name:PARK, KEVIN HYEUN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:HYEUN
Last Name:PARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 JUSTIN LN APT 2130
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2652
Mailing Address - Country:US
Mailing Address - Phone:806-577-3975
Mailing Address - Fax:
Practice Address - Street 1:5721 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-2196
Practice Address - Country:US
Practice Address - Phone:512-942-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist