Provider Demographics
NPI:1598117012
Name:PARK, SUSAN S
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
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 1:15131 E CRESTLINE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-2517
Mailing Address - Country:US
Mailing Address - Phone:720-289-2021
Mailing Address - Fax:
Practice Address - Street 1:15131 E CRESTLINE AVE
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-2517
Practice Address - Country:US
Practice Address - Phone:720-289-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist