Provider Demographics
NPI:1811216633
Name:PARK, ANISSA B (PHARM D)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:B
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 14TH ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-1202
Mailing Address - Country:US
Mailing Address - Phone:201-499-0018
Mailing Address - Fax:201-499-0018
Practice Address - Street 1:100 14TH ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1202
Practice Address - Country:US
Practice Address - Phone:201-499-0018
Practice Address - Fax:201-499-0018
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03162500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist