Provider Demographics
NPI:1902180482
Name:PARK, JAMI MICHELLE
Entity Type:Individual
Prefix:
First Name:JAMI
Middle Name:MICHELLE
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 1:124 N CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62681-1486
Mailing Address - Country:US
Mailing Address - Phone:217-322-3333
Mailing Address - Fax:217-322-6229
Practice Address - Street 1:124 N CONGRESS ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62681-1486
Practice Address - Country:US
Practice Address - Phone:217-322-3333
Practice Address - Fax:217-322-6229
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-040991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist