Provider Demographics
NPI:1689162224
Name:PARK, SO YEUN (PHARMD)
Entity Type:Individual
Prefix:
First Name:SO YEUN
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 1:373 E MAIN ST APT 102
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-3130
Mailing Address - Country:US
Mailing Address - Phone:574-780-6159
Mailing Address - Fax:
Practice Address - Street 1:242 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026-2967
Practice Address - Country:US
Practice Address - Phone:877-469-4334
Practice Address - Fax:888-987-4763
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03893900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist