Provider Demographics
NPI:1245861889
Name:PARK, CHONG YOP (RPH)
Entity type:Individual
Prefix:
First Name:CHONG
Middle Name:YOP
Last Name:PARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 LAVISTA RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3951
Mailing Address - Country:US
Mailing Address - Phone:404-633-4201
Mailing Address - Fax:404-315-4402
Practice Address - Street 1:2205 LAVISTA RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3951
Practice Address - Country:US
Practice Address - Phone:404-633-4201
Practice Address - Fax:404-315-4402
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019385183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist