Provider Demographics
NPI:1811297971
Name:PARK, SONG WOOK (RPH)
Entity type:Individual
Prefix:MR
First Name:SONG
Middle Name:WOOK
Last Name:PARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 ELDEN ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4512
Mailing Address - Country:US
Mailing Address - Phone:571-262-2970
Mailing Address - Fax:571-262-2973
Practice Address - Street 1:413 ELDEN ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4512
Practice Address - Country:US
Practice Address - Phone:571-262-2970
Practice Address - Fax:571-262-2973
Is Sole Proprietor?:No
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist