Provider Demographics
NPI:1821721887
Name:PARK, JI
Entity Type:Individual
Prefix:
First Name:JI
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 1:1505 MASSACHUSETTS AVE UNIT 11
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3842
Mailing Address - Country:US
Mailing Address - Phone:978-995-6508
Mailing Address - Fax:
Practice Address - Street 1:2100 HIGHLAND CORPORATE DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-8703
Practice Address - Country:US
Practice Address - Phone:800-746-7287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH06269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist