Provider Demographics
NPI:1700424298
Name:PARK, JI YOUNG
Entity Type:Individual
Prefix:
First Name:JI YOUNG
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 1:903 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:RED SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28377-1641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:903 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-1641
Practice Address - Country:US
Practice Address - Phone:910-843-3459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-15
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist