Provider Demographics
NPI:1295499945
Name:PARK, KYLIN HUNTER
Entity type:Individual
Prefix:
First Name:KYLIN
Middle Name:HUNTER
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLIN
Other - Middle Name:HUNTER
Other - Last Name:WILHELM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8634 CRANESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TERRA ALTA
Mailing Address - State:WV
Mailing Address - Zip Code:26764-7387
Mailing Address - Country:US
Mailing Address - Phone:304-698-4999
Mailing Address - Fax:
Practice Address - Street 1:13164 GARRETT HWY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1117
Practice Address - Country:US
Practice Address - Phone:301-334-9129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist