Provider Demographics
NPI:1700211893
Name:PARK, JANE S
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:S
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 1:35 KENSICO RD
Mailing Address - Street 2:WALGREENS
Mailing Address - City:THORNWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:10594-1143
Mailing Address - Country:US
Mailing Address - Phone:914-747-0239
Mailing Address - Fax:
Practice Address - Street 1:35 KENSICO RD
Practice Address - Street 2:WALGREENS
Practice Address - City:THORNWOOD
Practice Address - State:NY
Practice Address - Zip Code:10594-1143
Practice Address - Country:US
Practice Address - Phone:914-747-0239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-07
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist