Provider Demographics
NPI:1588673669
Name:PARK, HEARAN ROSE
Entity Type:Individual
Prefix:
First Name:HEARAN
Middle Name:ROSE
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:HHC 18TH MEDCOM BOX 434
Mailing Address - Street 2:GENERAL HOSPITAL
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205
Mailing Address - Country:KR
Mailing Address - Phone:8227-917-7984
Mailing Address - Fax:
Practice Address - Street 1:HHC 18TH MEDCOM BOX 434
Practice Address - Street 2:GENERAL HOSPITAL
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205
Practice Address - Country:KR
Practice Address - Phone:8227-917-7984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302410975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist