Provider Demographics
NPI:1750572251
Name:PARK, WILLIAM THOMAS
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BILLY
Other - Middle Name:THOMAS
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARM D
Mailing Address - Street 1:10497 E TORTILLA CREEK CT
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85218-5107
Mailing Address - Country:US
Mailing Address - Phone:256-652-8985
Mailing Address - Fax:
Practice Address - Street 1:101 CIBEQUE CIRCLE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:520-475-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist