Provider Demographics
NPI:1619258100
Name:PARK, JOHN BANSUK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BANSUK
Last Name:PARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 W BROADWAY
Mailing Address - Street 2:APT A219
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2385
Mailing Address - Country:US
Mailing Address - Phone:858-344-4142
Mailing Address - Fax:
Practice Address - Street 1:20200 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-7821
Practice Address - Country:US
Practice Address - Phone:562-274-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist