Provider Demographics
NPI:1669751772
Name:PARK, TAE E (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TAE
Middle Name:E
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 1:230 PARK AVE
Mailing Address - Street 2:M-SP1-01
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 PARK AVE
Practice Address - Street 2:M-SP1-01
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07901
Practice Address - Country:US
Practice Address - Phone:973-443-8436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0012063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist