Provider Demographics
NPI:1790319978
Name:PARK, JACQUELINE JUNG AH (RPH)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JUNG AH
Last Name:PARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11515 ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-3852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11515 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-3852
Practice Address - Country:US
Practice Address - Phone:562-402-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist