Provider Demographics
NPI:1669692794
Name:PARK, SUSIE H (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:H
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 TAPESTRY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-0684
Mailing Address - Country:US
Mailing Address - Phone:949-725-0599
Mailing Address - Fax:323-442-1681
Practice Address - Street 1:1985 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-442-1675
Practice Address - Fax:323-442-1681
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH521321835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric