Provider Demographics
NPI:1578845368
Name:PARK, INSOOK
Entity Type:Individual
Prefix:
First Name:INSOOK
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5049
Practice Address - Country:US
Practice Address - Phone:718-584-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist