Provider Demographics
NPI:1619137619
Name:PARK, CHANMYUNG (RPH)
Entity Type:Individual
Prefix:
First Name:CHANMYUNG
Middle Name:
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 1:4043 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1516
Mailing Address - Country:US
Mailing Address - Phone:212-795-1240
Mailing Address - Fax:212-795-9167
Practice Address - Street 1:4043 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1516
Practice Address - Country:US
Practice Address - Phone:212-795-1240
Practice Address - Fax:212-795-9167
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist