Provider Demographics
NPI:1629559125
Name:PARK, IRENE (PHARMD)
Entity Type:Individual
Prefix:
First Name:IRENE
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 1:1004 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-1901
Mailing Address - Country:US
Mailing Address - Phone:949-769-1199
Mailing Address - Fax:
Practice Address - Street 1:4627 CARMEL MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-6613
Practice Address - Country:US
Practice Address - Phone:858-523-1847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP452519183500000X
NJ28RI03958800183500000X
CA86114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist