Provider Demographics
NPI:1336436161
Name:PARK, GLORIA Y (PHARM D)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:Y
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11765 SW 134TH TER
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1581
Mailing Address - Country:US
Mailing Address - Phone:503-820-8750
Mailing Address - Fax:
Practice Address - Street 1:8801 NE HAZEL DELL AVE
Practice Address - Street 2:T1883
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8145
Practice Address - Country:US
Practice Address - Phone:360-713-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60203858183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist