Provider Demographics
NPI:1629328281
Name:PARK, DIANA (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9562 ROSE VISTA CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-3268
Mailing Address - Country:US
Mailing Address - Phone:916-541-4622
Mailing Address - Fax:
Practice Address - Street 1:4220 MISSOURI FLAT RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6269
Practice Address - Country:US
Practice Address - Phone:530-344-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist