Provider Demographics
NPI:1790418390
Name:PARK, SANGWON JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:SANGWON
Middle Name:JAMES
Last Name:PARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W CERRITOS AVE UNIT 208
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6180
Mailing Address - Country:US
Mailing Address - Phone:714-262-0925
Mailing Address - Fax:
Practice Address - Street 1:1700 W CERRITOS AVE UNIT 208
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6180
Practice Address - Country:US
Practice Address - Phone:714-262-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist