Provider Demographics
NPI:1760859060
Name:PARK, MIN JOO
Entity Type:Individual
Prefix:
First Name:MIN JOO
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 1:3920 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2061
Mailing Address - Country:US
Mailing Address - Phone:718-224-2606
Mailing Address - Fax:718-224-8083
Practice Address - Street 1:3920 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2061
Practice Address - Country:US
Practice Address - Phone:718-224-2606
Practice Address - Fax:718-224-8083
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060853OtherPHARMACIST LICENSE