Provider Demographics
NPI:1184159097
Name:PARK, ALEX (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-7704
Mailing Address - Country:US
Mailing Address - Phone:903-595-3100
Mailing Address - Fax:903-595-3394
Practice Address - Street 1:2323 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-7704
Practice Address - Country:US
Practice Address - Phone:903-595-3100
Practice Address - Fax:903-595-3394
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11275183500000X
CA52097183500000X
TX41896183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist