Provider Demographics
NPI:1992836092
Name:PARK PHARMACY INC
Entity Type:Organization
Organization Name:PARK PHARMACY INC
Other - Org Name:PARK'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUNG IL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:206-527-3010
Mailing Address - Street 1:401 NE RAVENNA BLVD
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-8401
Mailing Address - Country:US
Mailing Address - Phone:206-527-3010
Mailing Address - Fax:206-527-2320
Practice Address - Street 1:401 NE RAVENNA BLVD
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-8401
Practice Address - Country:US
Practice Address - Phone:206-527-3010
Practice Address - Fax:206-527-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000020443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2108371OtherPK
WA6104301Medicaid
4901190001Medicare NSC