Provider Demographics
NPI:1861003048
Name:PARK, MIN J (PHARMD)
Entity Type:Individual
Prefix:
First Name:MIN
Middle Name:J
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1007
Mailing Address - Country:US
Mailing Address - Phone:617-208-1656
Mailing Address - Fax:617-870-7459
Practice Address - Street 1:495 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-1007
Practice Address - Country:US
Practice Address - Phone:617-208-1656
Practice Address - Fax:617-870-7459
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH238279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist