Provider Demographics
NPI:1356562268
Name:PARK, HANNAH
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 NORTH FWY STE 111
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77076-2941
Mailing Address - Country:US
Mailing Address - Phone:713-694-6789
Mailing Address - Fax:713-694-2789
Practice Address - Street 1:6500 NORTH FWY STE 111
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77076-2941
Practice Address - Country:US
Practice Address - Phone:713-694-6789
Practice Address - Fax:713-694-2789
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13893183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143667Medicaid