Provider Demographics
NPI:1801484480
Name:PARK, JEONG IN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JEONG
Middle Name:IN
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2182 LEMOINE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6009
Mailing Address - Country:US
Mailing Address - Phone:201-482-4705
Mailing Address - Fax:201-482-4905
Practice Address - Street 1:2182 LEMOINE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6009
Practice Address - Country:US
Practice Address - Phone:120-154-3864
Practice Address - Fax:201-482-4905
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02461600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI02461600OtherNJ BOARD OF PHARMACY