Provider Demographics
NPI:1578170437
Name:PARK, SANG JIN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:SANG
Middle Name:JIN
Last Name:PARK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S MANHATTAN PL APT 9
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4454
Mailing Address - Country:US
Mailing Address - Phone:515-745-0524
Mailing Address - Fax:
Practice Address - Street 1:504 S MANHATTAN PL APT 9
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-4454
Practice Address - Country:US
Practice Address - Phone:515-745-0524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist