Provider Demographics
NPI:1689253858
Name:PARK, BO YE
Entity Type:Individual
Prefix:
First Name:BO YE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 E LINCOLN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-2257
Mailing Address - Country:US
Mailing Address - Phone:714-776-1020
Mailing Address - Fax:714-776-7053
Practice Address - Street 1:1425 E LINCOLN AVE STE B
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-2257
Practice Address - Country:US
Practice Address - Phone:714-776-1020
Practice Address - Fax:714-776-7053
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist