Provider Demographics
NPI:1851722391
Name:PARK, JESSIE MYUNGAH
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:MYUNGAH
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 1:3000 HARBISON DR
Mailing Address - Street 2:T0827
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3909
Mailing Address - Country:US
Mailing Address - Phone:707-452-8119
Mailing Address - Fax:
Practice Address - Street 1:3000 HARBISON DR
Practice Address - Street 2:T0827
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-3909
Practice Address - Country:US
Practice Address - Phone:707-452-8119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist