Provider Demographics
NPI:1578045340
Name:PARK, YOUNG JAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:JAE
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 1:909 ALA LILIKOI ST APT 408
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-2437
Mailing Address - Country:US
Mailing Address - Phone:678-602-1259
Mailing Address - Fax:
Practice Address - Street 1:459 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1522
Practice Address - Country:US
Practice Address - Phone:808-433-3157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0299501835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care