Provider Demographics
NPI:1578156915
Name:PARK, AUSTIN JOONYONG (RPH)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JOONYONG
Last Name:PARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1306
Mailing Address - Country:US
Mailing Address - Phone:831-425-3911
Mailing Address - Fax:
Practice Address - Street 1:1055 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-5712
Practice Address - Country:US
Practice Address - Phone:831-393-9231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist